Nursing Theory alligood 8th edition

Nursing Theorists
AND THEIR WORK

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Nursing Theorists
AND THEIR WORK

Martha Raile Alligood, PhD, RN, ANEF

Professor Emeritus
College of Nursing
East Carolina University
Greenville, North Carolina

3251 Riverport Lane
St. Louis, Missouri 63043

NURSING THEORISTS AND THEIR WORK, EIGHTH EDITION ISBN: 978-0-323-09194-7

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Copyright © 2010, 2006, 2002, 1998, 1994, 1989, 1986 by Mosby, Inc., an affiliate of Elsevier Inc.

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Notices
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Library of Congress Cataloging-in-Publication Data
Nursing theorists and their work / [edited by] Martha Raile Alligood. — Eighth edition.
   p. ; cm.
  Includes biographical references and index.
  ISBN 978-0-323-09194-7 9pbk. ; alk. Paper)
  I. Alligood, Martha Raile, editor of compilation.
  [DNLM: 1. Nursing Theory. 2. Models, Nursing. 3. Nurses—Biography. Philosophy, Nursing. WY 86]
  RT84.5
  610.7301—dc23

2013023220

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Dedicated to the memory of my mother:
Winifred Havener Raile, RN
1914-2012
Class of 1936,

Good Samaritan School of Nursing,
Zanesville, Ohio

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Herdis Alvsvåg, RN, Cand Polit Contributors
Associate Professor
Department of Education and Health Promotion Janet Witucki Brown, PhD, RN, CNE
University of Bergen Associate Professor
Bergen, Norway; College of Nursing
Associate Professor II University of Tennessee
Bergen Deaconess University College Knoxville, Tennessee
Bergen, Norway
Karen A. Brykczynski, PhD, RN, FNP-BC,
Donald E. Bailey, Jr., PhD, RN FAANP, FAAN
Associate Professor Professor
School of Nursing School of Nursing at Galveston
Duke University The University of Texas Medical Branch
Durham, North Carolina Galveston, Texas

Barbara Banfield, RN, PhD Sherrilyn Coffman, PhD, RN
Farmington Hills, Michigan Professor and Assistant Dean
School of Nursing
Violeta A. Berbiglia, EdD, MSN, RN Nevada State College
Associate Professor, Retired Henderson, Nevada
The University of Texas Health Science Center
at San Antonio School of Nursing Doris Dickerson Coward, RN, PhD
San Antonio, Texas Associate Professor, Retired
School of Nursing
Debra A. Bournes, RN, PhD The University of Texas at Austin
Director of Nursing Austin, Texas
New Knowledge and Innovation
University Health Network Thérèse Dowd, PhD, RN, HTCP
Toronto, Canada Associate Professor Emeritus
College of Nursing
Nancy Brookes, PhD, RN, BC, MSc (A), The University of Akron
CPMHN (C) Akron, Ohio
Nurse Scholar and Adjunct Professor
Royal Ottawa Health Care Group Nellie S. Droes, DNSc, RN
Royal Ottawa Mental Health Centre Associate Professor, Emerita
University of Ottawa Faculty of Health Sciences College of Nursing
Ottawa, Ontario, Canada East Carolina University
Greenville, North Carolina

vii

viii Contributors D. Elizabeth Jesse, PhD, RN, CNM
Margaret E. Erickson, PhD, RN, CNS, AHN-BC Associate Professor
College of Nursing
Executive Director East Carolina University
American Holistic Nurses’ Certification Corporation Greenville, North Carolina
Cedar Park, Texas
Mary E. Gunther, RN, MSN, PhD Lisa Kitko, PhD, RN, CCRN
Associate Professor Assistant Professor
College of Nursing School of Nursing
University of Tennessee The Pennsylvania State University
Knoxville, Tennessee University Park, Pennsylvania
Dana M. Hansen, RN, MSN, PhD
Assistant Professor Theresa Gunter Lawson, PhD, APRN, FNP-BC
College of Nursing Assistant Professor
Kent State University Department of Nursing
Kent, Ohio Lander University
Sonya R. Hardin, PhD, RN, CCRN, NP-C Greenwood, South Carolina
Professor
College of Nursing Unni Å. Lindström, PhD, RN
East Carolina University Professor
Greenville, North Carolina Department of Caring Science
Robin Harris, PhD, ANP-BC, ACNS-BC Faculty of Social and Caring Sciences
Nurse Practitioner Åbo Academy University
Wellmont CVA Heart Institute Vasa, Finland
Kingsport, Tennessee
Patricia A. Higgins, PhD, RN M. Katherine Maeve, PhD, RN
Assistant Professor Nurse Researcher
Frances Payne Bolton School of Nursing Charlie Norwood VAMC
Case Western Reserve University Augusta, Georgia
Cleveland, Ohio
Bonnie Holaday, DNS, RN, FAAN Marilyn R. McFarland, PhD, RN, FNP, BC, CTN
Professor and Director, Graduate Studies Associate Professor of Nursing and Family Nurse
School of Nursing and Institute on Family and Practitioner
Urban Health and Wellness Center
Neighborhood Life University of Michigan
Clemson University Flint, Michigan
Clemson, South Carolina
Eun-Ok Im, PhD, MPH, RN, CNS, FAAN Gwen McGhan, PhD(c), RN
Professor and Marjorie O. Rendell Endowed Jonas/Hartford Doctoral Scholar
School of Nursing
Professor The Pennsylvania State University
School of Nursing University Park, Pennsylvania
The University of Pennsylvania
Philadelphia, Pennsylvania Molly Meighan, RNC, PhD
Professor Emerita
Division of Nursing
Carson-Newman College
Jefferson City, Tennessee

Contributors ix

Patricia R. Messmer, PhD, RN-BC, FAAN Marguerite J. Purnell, PhD, RN, AHN-BC
Director Assistant Professor
Patient Care Services Research Christine E. Lynn College of Nursing
Children’s Mercy Hospital and Clinics Florida Atlantic University
Kansas City, Missouri Boca Raton, Florida

Gail J. Mitchell, PhD, RN, MScN, BScN Teresa J. Sakraida, PhD, RN
Professor Assistant Professor
School of Nursing College of Nursing
Chair/Director University of Colorado, Denver
York-UHN Nursing Academy Aurora, Colorado
York University
Toronto, Ontario, Canada Karen Moore Schaefer, PhD, RN
Associate Chair and Associate Professor, Retired
Lisbet Lindholm Nyström, PhD, RN Department of Nursing
Associate Professor College of Health Professions
Department of Caring Science Temple University
Faculty of Social and Caring Sciences Philadelphia, Pennsylvania
Åbo Academy University
Vasa, Finland Ann M. Schreier, PhD, RN
Associate Professor
Janice Penrod, PhD, RN, FGSA, FAAN College of Nursing
Director, Center for Nursing Research East Carolina University
Associate Professor Greenville, North Carolina
School of Nursing
The Pennsylvania State University Carrie J. Scotto, PhD, RN
University Park, Pennsylvania Associate Professor
College of Nursing
Susan A. Pfettscher, DNSc, RN University of Akron
Retired Akron, Ohio
Bakersfield, California
Christina L. Sieloff, PhD, RN, NE, BC
Kenneth D. Phillips, PhD, RN Associate Professor
Professor and Associate Dean for Research and College of Nursing
Evaluation Montana State University
College of Nursing Billings, Montana
The University of Tennessee
Knoxville, Tennessee Janet L. Stewart, PhD, RN
Assistant Professor
Marie E. Pokorny, PhD, RN Department of Health Promotion and Development
Director of the PhD Program School of Nursing
College of Nursing University of Pittsburgh
East Carolina University Pittsburgh, Pennsylvania
Greenville, North Carolina

x Contributors Joan E. Zetterlund, PhD, RN
Danuta M. Wojnar, PhD, RN, MEd, IBCLC Professor Emerita of Nursing
School of Nursing
Assistant Professor North Park University
College of Nursing Chicago, Illinois
Seattle University
Seattle, Washington

Jean Logan, RN, PhD Reviewers
Professor
Grand View University Nancy Stahl, RN, MSN, CNE
Des Moines, Iowa Associate Professor
BSN Coordinator
Karen Pennington, PhD, RN University of North Georgia
Associate Professor Dahlonega, Georgia
Regis University
Denver, Colorado

xi

About the Editor

Martha Raile Alligood is professor emeritus at East Carolina University College of Nursing in Greenville,
North Carolina, where she was Director of the Nursing PhD program. A graduate of Good Samaritan School of
Nursing, she also holds a bachelor of sacred literature (BSL) from Johnson University, a BSN from University of
Virginia, an MS from The Ohio State University, and a PhD from New York University.

Her career in nursing education began in Zimbabwe (formerly Rhodesia) in Africa and has included graduate
appointments at the University of Florida, University of South Carolina, and University of Tennessee. Among
her professional memberships are Epsilon and Beta Nu Chapters of Sigma Theta Tau International (STTI),
Southern Nursing Research Society (SNRS), North Carolina Nurses Association/American Nurses Association
(NCNA/ANA), and Society of Rogerian Scholars (SRS).

A recipient of numerous awards and honors, she is a Fellow of the National League for Nursing (NLN) Acad-
emy of Nursing Education, received the SNRS Leadership in Research Award, and was honored with the East
Carolina University Chancellors’s Women of Distinction Award. A member of the Board of Trustees at Johnson
University, Dr. Alligood chairs the Academic Affairs Committee.

She served as contributing editor for the Theoretical Concerns column in Nursing Science Quarterly, Vol. 24,
2011, and is author/editor of Nursing Theory: Utilization & Application, fifth edition, as well as this eighth edition
of Nursing Theorists and Their Work.
xii

Preface

This book is a tribute to nursing theorists and a classic in theoretical nursing literature. It presents many
major thinkers in nursing, reviews their important knowledge-building ideas, lists their publications, and
points the reader to those using the works and writing about them in their own theoretical publications.
Unit I introduces the text with a brief history of nursing knowledge development and its significance to the
discipline and practice of the profession in Chapter 1. Other chapters in Unit I discuss the history, philosophy
of science and the framework for analysis used throughout the text, logical reasoning and theory development
processes, and the structure of knowledge and types of knowledge within that structure. Ten works from earlier
editions of Nursing Theorists and Their Work are introduced and discussed briefly as nursing theorists of
historical significance in Chapter 5. They are Peplau; Henderson; Abdellah; Wiedenbach; Hall; Travelbee;
Barnard; Adam; Roper, Logan, Tierney, and Orlando.

In Unit II, the philosophies of Nightingale, Watson, Ray, Benner, Martinsen, and Eriksson are presented.
Unit III includes nursing models by Levine, Rogers, Orem, King, Neuman, Roy, and Johnson. The work of
Boykin and Schoenhofer begins Unit IV on nursing theory, followed by the works of Meleis; Pender; Leininger;
Newman; Parse; Erickson, Tomlin, and Swain; and the Husteds. Unit V presents middle range theoretical works
of Mercer; Mishel; Reed; Wiener and Dodd; Eakes, Burke, and Hainsworth; Barker; Kolcaba; Beck; Swanson;
Ruland and Moore. Unit VI addresses the state of the art and science of nursing theory from three perspectives:
the philosophy of nursing science, the expansion of theory development, and the global nature and expanding
use of nursing theoretical works.

The works of nurse theorists from around the world are featured in this text, including works by international
theorists that have been translated into English. Nursing Theorists and Their Work has also been translated into
numerous languages for nursing faculty and students in other parts of the world as well as nurses in practice.

Nurses and students at all stages of their education are interested in learning about nursing theory and
the use of nurse theorist works from around the world. Those who are just beginning their nursing education,
such as associate degree and baccalaureate students, will be interested in the concepts, definitions, and theoreti-
cal assertions. Graduate students, at the masters and doctoral levels, will be more interested in the logical form,
acceptance by the nursing community, the theoretical sources for theory development, and the use of empirical
data. The references and extensive bibliographies are particularly useful to graduate students for locating
primary and secondary sources that augment the websites specific to the theorist. The following comprehensive
websites are excellent resources with information about theory resources and links to the individual theorists
featured in this book:

• Nursing Theory link page, Clayton College and State University, Department of Nursing: http: //www.
healthsci.clayton.edu/eichelberger/nursing.htm

• Nursing Theory page, Hahn School of Nursing and Health Science, University of San Diego: http: //www.
sandiego.edu/academics/nursing/theory/

• A comprehensive collection of nursing theory media, The Nurse Theorists: Portraits of Excellence, Vol. I and
Vol. II and Nurse Theorists: Excellence in Action: http: //www.fitne.net/

The works of the theorists presented in this text have stimulated phenomenal growth in nursing literature and
enriched the professional lives of nurses around the world by guiding nursing research, education, administra-
tion, and practice. The professional growth continues to multiply as we analyze and synthesize these works,

xiii

xiv Preface

generate new ideas, and develop new theory and applications for education in the discipline and quality care in
practice by nurses.

The work of each theorist is presented with a framework using the following headings to facilitate uniformity
and comparison among the theorists and their works:

• Credentials and background
• Theoretical sources for theory development
• Use of empirical data
• Major concepts and definitions
• Major assumptions
• Theoretical assertions
• Logical form
• Acceptance by the nursing community
• Further development
• Critique of the work
• Summary
• Case study based on the work
• Critical thinking activities
• Points for further study
• References and bibliographies

Acknowledgments
I am very thankful to the theorists who critiqued the original and many subsequent chapters about themselves
to keep the content current and accurate. The work of Paterson and Zderad was omitted at their request.

I am very grateful to those who have contributed or worked behind the scenes with previous editions to
develop this text over the years. In the third edition, Martha Raile Alligood joined Ann Marriner Tomey, to
reorder the chapters, serve as a contributing author, and edit for consistency with the new organization of the
text. Subsequently Dr. Tomey recommended Dr. Alligood to Mosby-Elsevier to design and coedit a practice
focused text, Nursing Theory: Utilization and Application and based on Alligood’s expertise in nursing theory,
invited her to become coeditor and contributing author to future editions of this text, Nursing Theorists and Their
Work. I want to recognize and thank Ann Marriner Tomey for her vision to develop the first six editions of this
book. Her mentorship, wisdom, and collegial friendship have been special to me in my professional career. Most
of all, she is to be commended for her dedication to this text that continues to make an important and valuable
contribution to the discipline and the profession of nursing. I wish Ann well in her retirement.

Finally, I would like to thank the publishers at Mosby-Elsevier for their guidance and assistance through
the years to bring this text to this eighth edition. The external reviews requested by Mosby-Elsevier editors
have contributed to the successful development of each new edition. The chapter authors who over the years
have contributed their expert knowledge of the theorists and their work continue to make a most valuable
contribution.

Martha Raile Alligood

Contents

UNIT I Evolution of Nursing Theories

1 Introduction to Nursing Theory: Its History, Significance, and Analysis, 2
Martha Raile Alligood
2 History and Philosophy of Science, 14
Sonya R. Hardin
3 Theory Development Process, 23
Sonya R. Hardin
4 The Structure of Specialized Nursing Knowledge, 38
Martha Raile Alligood
5 Nursing Theorists of Historical Significance, 42
Marie E. Pokorny

Hildegard E. Peplau
Virginia Henderson
Faye Glenn Abdellah
Ernestine Wiedenbach
Lydia Hall
Joyce Travelbee
Kathryn E. Barnard
Evelyn Adam
Nancy Roper, Winifred W. Logan, and Alison J. Tierney
Ida Jean (Orlando) Pelletier

UNIT II Nursing Philosophies

6 Florence Nightingale: Modern Nursing, 60
Susan A. Pfettscher
7 Jean Watson: Watson’s Philosophy and Theory of Transpersonal Caring, 79
D. Elizabeth Jesse and Martha R. Alligood
8 Marilyn Anne Ray: Theory of Bureaucratic Caring, 98
Sherrilyn Coffman
9 Patricia Benner: Caring, Clinical Wisdom, and Ethics in Nursing Practice, 120
Karen A. Brykczynski
10 Kari Martinsen: Philosophy of Caring, 147
Herdis Alvsvåg
11 Katie Eriksson: Theory of Caritative Caring, 171
Unni Å. Lindström, Lisbet Lindholm Nyström, and Joan E. Zetterlund

xv

xvi Contents

UNIT III Nursing Conceptual Models

12 Myra Estrin Levine: The Conservation Model, 204
Karen Moore Schaefer
13 Martha E. Rogers: Unitary Human Beings, 220
Mary E. Gunther
14 Dorothea E. Orem: Self-Care Deficit Theory of Nursing, 240
Violeta A. Berbiglia and Barbara Banfield
15 Imogene M. King: Conceptual System and Middle-Range Theory of Goal Attainment, 258
Christina L. Sieloff and Patricia R. Messmer
16 Betty Neuman: Systems Model, 281
Theresa G. Lawson
17 Sister Callista Roy: Adaptation Model, 303
Kenneth D. Phillips and Robin Harris
18 Dorothy E. Johnson: Behavioral System Model, 332
Bonnie Holaday

UNIT IV Nursing Theories

19 Anne Boykin and Savina O. Schoenhofer: The Theory of Nursing as Caring: A Model for
Transforming Practice, 358

Marguerite J. Purnell
20 Afaf Ibrahim Meleis: Transitions Theory, 378
Eun-Ok Im
21 Nola J. Pender: Health Promotion Model, 396
Teresa J. Sakraida
22 Madeleine M. Leininger: Culture Care Theory of Diversity and Universality, 417
Marilyn R. McFarland
23 Margaret A. Newman: Health as Expanding Consciousness, 442
Janet Witucki Brown and Martha Raile Alligood
24 Rosemarie Rizzo Parse: Humanbecoming, 464
Debra A. Bournes and Gail J. Mitchell
25 Helen C. Erickson, Evelyn M. Tomlin, Mary Ann P. Swain:

Modeling and Role-Modeling, 496
Margaret E. Erickson
26 Gladys L. Husted and James H. Husted: Symphonological Bioethical Theory, 520
Carrie Scotto

UNIT V Middle Range Nursing Theories

27 Ramona T. Mercer: Maternal Role Attainment—Becoming a Mother, 538
Molly Meighan
28 Merle H. Mishel: Uncertainty in Illness Theory, 555
Donald E. Bailey, Jr. and Janet L. Stewart

Contents xvii

29 Pamela G. Reed: Self-Transcendence Theory, 574
Doris D. Coward
30 Carolyn L. Wiener and Marylin J. Dodd: Theory of Illness Trajectory, 593
Janice Penrod, Lisa Kitko, and Gwen McGhan
31 Georgene Gaskill Eakes, Mary Lermann Burke, and Margaret A. Hainsworth:

Theory of Chronic Sorrow, 609
Ann M. Schreier and Nellie S. Droes
32 Phil Barker: The Tidal Model of Mental Health Recovery, 626
Nancy Brookes
33 Katharine Kolcaba: Theory of Comfort, 657
Thérèse Dowd
34 Cheryl Tatano Beck: Postpartum Depression Theory, 672
M. Katherine Maeve
35 Kristen M. Swanson: Theory of Caring, 688
Danuta M. Wojnar
36 Cornelia M. Ruland and Shirley M. Moore: Peaceful End-of-Life Theory, 701
Patricia A. Higgins and Dana M. Hansen

UNIT VI The Future of Nursing Theory

37 State of the Art and Science of Nursing Theory, 712
Martha Raile Alligood
Index, 721

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IUNIT

Evolution of Nursing Theories

n Searching for specialized nursing knowledge led nurse scholars to theories
that guide research, education, administration, and professional practice.

n Nursing followed a path from concepts to conceptual frameworks to models
to theories, and finally to middle range theory, in this theory utilization era.

n Nursing history demonstrates the significance of theory for nursing as a
division of education (the discipline) and a specialized field of practice
(the profession).

n Knowledge of the theory development process is basic to a personal
understanding of the theoretical works of the discipline.

n Analysis facilitates learning through systematic review and critical reflection
of the theoretical works of the discipline.

n Theory analysis begins the process of identifying a decision making
framework for nursing research or nursing practice.

1CHA P T ER

Introduction to Nursing Theory:
Its History, Significance, and Analysis

Martha Raile Alligood

“The systematic accumulation of knowledge is essential to progress in any
profession . . . however theory and practice must be constantly interactive.

Theory without practice is empty and practice without theory is blind.”

(Cross, 1981, p. 110).

This text is designed to introduce the reader to Bixler, 1959; Chinn & Kramer, 2011; George, 2011;
nursing theorists and their work. Nursing theory Im & Chang, 2012; Judd, Sitzman & Davis, 2010;
became a major theme in the last century, and it con- Meleis, 2007; Shaw, 1993).
tinues today to stimulate phenomenal professional
growth and expansion of nursing literature and edu- This chapter introduces nursing theory from three
cation. Selected nursing theorists are presented in different perspectives: history, significance, and anal-
this text to expose students at all levels of nursing ysis. Each perspective contributes understanding of
to a broad range of nurse theorists and various types the contributions of the nursing theorists and their
of theoretical works. Nurses of early eras delivered work. A brief history of nursing development from
excellent care to patients; however, much of what vocational to professional describes the search for
was known about nursing was passed on through nursing substance that led to this exciting time in
forms of education that were focused on skills and nursing history as linkages were strengthened be-
functional tasks. Whereas many nursing practices tween nursing as an academic discipline and as pro-
seemed effective, they were not tested nor used uni- fessional practice. The history of this development
formly in practice or education. Therefore, a major provides context and a perspective to understand the
goal put forth by nursing leaders in the twentieth continuing significance of nursing theory for the dis-
century was the development of nursing knowledge cipline and profession of nursing. The history and
on which to base nursing practice, improve quality of significance of nursing theory leads logically into
care, and gain recognition of nursing as a profession. analysis, the third section of the chapter and final
The history of nursing clearly documents sustained perspective. Analysis of nursing theoretical works
efforts toward the goal of developing a specialized and its role in knowledge development is presented
body of nursing knowledge to guide nursing practice as an essential process of critical reflection. Criteria
(Alligood, 2010a; Alligood & Tomey, 1997; Bixler & for analysis of the works of theorists are presented,
along with a brief discussion of how each criterion

Previous authors: Martha Raile Alligood, Elizabeth Chong Choi, Juanita Fogel Keck, and Ann Marriner Tomey.
2

CHAPTER 1  Introduction to Nursing Theory: Its History, Significance, and Analysis 3

contributes to a deeper understanding of the work and individual hospital procedure manuals (Alligood,
(Chinn & Kramer, 2011). 2010a; Kalisch & Kalisch, 2003). Although some nurs-
ing leaders aspired for nursing to be recognized as a
History of Nursing Theory profession and become an academic discipline, nursing
practice continued to reflect its vocational heritage
The history of professional nursing began with Flor- more than a professional vision. The transition from
ence Nightingale. Nightingale envisioned nurses as vocation to profession included successive eras of his-
a body of educated women at a time when women tory as nurses began to develop a body of specialized
were neither educated nor employed in public service. knowledge on which to base nursing practice. Nurs-
Following her wartime service of organizing and car- ing had begun with a strong emphasis on practice,
ing for the wounded in Scutari during the Crimean and nurses worked throughout the century toward
War, Nightingale’s vision and establishment of a School the development of nursing as a profession. Progress
of Nursing at St. Thomas’ Hospital in London marked toward the goal of developing a specialized basis for
the birth of modern nursing. Nightingale’s pioneering nursing practice has been viewed from the perspec-
activities in nursing practice and education and her tive of historical eras recognizing the thrust toward
subsequent writings became a guide for establishing professional development within each era (Alligood,
nursing schools and hospitals in the United States at 2010a; Alligood & Tomey, 1997).
the beginning of the twentieth century (Kalisch &
Kalisch, 2003; Nightingale, 1859/1969). The curriculum era addressed the question of
what content nurses should study to learn how to be
Nightingale’s (1859/1969) vision of nursing has a nurse. During this era, the emphasis was on what
been practiced for more than a century, and theory courses nursing students should take, with the goal
development in nursing has evolved rapidly over the of arriving at a standardized curriculum (Alligood,
past 6 decades, leading to the recognition of nursing 2010a). By the mid-1930s, a standardized curriculum
as an academic discipline with a specialized body had been published and adopted by many diploma
of knowledge (Alligood, 2010a, 2010b; Alligood & programs. However, the idea of moving nursing edu-
Tomey, 2010; Bixler & Bixler, 1959; Chinn & Kramer, cation from hospital-based diploma programs into
2011; Fawcett, 2005; Im & Chang, 2012; Walker & colleges and universities also emerged during this
Avant, 2011). It was during the mid-1800s that Night- era (Judd, Sitzman & Davis, 2010). In spite of this
ingale recognized the unique focus of nursing and early idea for nursing education, it was the middle of
declared nursing knowledge as distinct from medical the century before many states acted upon this goal,
knowledge. She described a nurse’s proper function and during the second half of the twentieth century,
as putting the patient in the best condition for nature diploma programs began closing and significant
(God) to act upon him or her. She set forth the follow- numbers of nursing education programs opened in
ing: that care of the sick is based on knowledge of colleges and universities (Judd, Sitzman, & Davis,
persons and their surroundings—a different knowl- 2010; Kalisch & Kalisch, 2003). The curriculum era
edge base than that used by physicians in their prac- emphasized course selection and content for nursing
tice (Nightingale, 1859/1969). Despite this early edict programs and gave way to the research era, which
from Nightingale in the 1850s, it was 100 years later, focused on the research process and the long-range
during the 1950s, before the nursing profession began goal of acquiring substantive knowledge to guide
to engage in serious discussion of the need to develop nursing practice.
nursing knowledge apart from medical knowledge to
guide nursing practice. This beginning led to aware- As nurses increasingly sought degrees in higher
ness of the need to develop nursing theory (Alligood, education, the research emphasis era began to emerge.
2010a; Alligood, 2004; Chinn & Kramer, 2011; Meleis, This era began during the mid-century as more nurse
2007; Walker & Avant, 2011). Until the emergence of leaders embraced higher education and arrived at a
nursing as a science in the 1950s, nursing practice was common understanding of the scientific age—that
based on principles and traditions that were handed research was the path to new nursing knowledge.
down through an apprenticeship model of education Nurses began to participate in research, and research
courses were included in the nursing curricula of early

4 UNIT I  Evolution of Nursing Theories in education, administration, and practice” (p. 4). An
developing graduate nursing programs (Alligood, important precursor to the theory era was the gen-
2010a). In the mid-1970s, an evaluation of the first eral acceptance of nursing as a profession and an
25 years of the journal Nursing Research revealed that academic discipline in its own right.
nursing studies lacked conceptual connections and
theoretical frameworks, accentuating the need for The theory era was a natural outgrowth of the re-
conceptual and theoretical frameworks for develop- search and graduate education eras (Alligood, 2010a;
ment of specialized nursing knowledge (Batey, 1977). Im & Chang, 2012). The explosive proliferation of
Awareness of the need for concept and theory devel- nursing doctoral programs from the 1970s and
opment coincided with two other significant mile- nursing theory literature substantiated that nursing
stones in the evolution of nursing theory. The first doctorates should be in nursing (Nicoll, 1986, 1992,
milestone is the standardization of curricula for nurs- 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer,
ing master’s education by the National League for 2009; 2012). As understanding of research and
Nursing accreditation criteria for baccalaureate and knowledge development increased, it became obvi-
higher-degree programs, and the second is the deci- ous that research without conceptual and theoretical
sion that doctoral education for nurses should be in frameworks produced isolated information. Rather,
nursing (Alligood, 2010a). there was an understanding that research and theory
together were required to produce nursing science
The research era and the graduate education era (Batey, 1977; Fawcett, 1978; Hardy, 1978). Doctoral
developed in tandem. Master’s degree programs in education in nursing began to flourish with the
nursing emerged across the country to meet the pub- introduction of new programs and a strong emphasis
lic need for nurses for specialized clinical nursing on theory development and testing. The theory
practice. Many of these graduate programs included era accelerated as works began to be recognized as
a course that introduced the student to the research theory, having been developed as frameworks for
process. Also during this era, nursing master’s pro- curricula and advanced practice guides. In fact, it
grams began to include courses in concept develop- was at the Nurse Educator Conference in New York
ment and nursing models, introducing students to City in 1978 that theorists were recognized as nurs-
early nursing theorists and knowledge development ing theorists and their works as nursing conceptual
processes (Alligood, 2010a). Development of nursing models and theories (Fawcett, 1984; Fitzpatrick &
knowledge was a major force during this period. The Whall, 1983).
baccalaureate degree began to gain wider acceptance
as the first educational level for professional nursing, The 1980s was a period of major developments in
and nursing attained nationwide recognition and nursing theory that has been characterized as a tran-
acceptance as an academic discipline in higher edu- sition from the pre-paradigm to the paradigm period
cation. Nurse researchers worked to develop and (Fawcett, 1984; Hardy, 1978; Kuhn, 1970). The pre-
clarify a specialized body of nursing knowledge, with vailing nursing paradigms (models) provided per-
the goals of improving the quality of patient care, spectives for nursing practice, administration, educa-
providing a professional style of practice, and achiev- tion, research, and further theory development. In
ing recognition as a profession. There were debates the 1980s, Fawcett’s seminal proposal of four global
and discussions in the 1960s regarding the proper nursing concepts as a nursing metaparadigm served
direction and appropriate discipline for nursing as an organizing structure for existing nursing frame-
knowledge development. In the 1970s, nursing con- works and introduced a way of organizing individual
tinued to make the transition from vocation to pro- theoretical works in a meaningful structure (Fawcett,
fession as nurse leaders debated whether nursing 1978, 1984, 1993; Fitzpatrick & Whall, 1983). Clas-
should be other-discipline based or nursing based. sifying the nursing models as paradigms within a
History records the outcome, that nursing practice metaparadigm of the person, environment, health,
is to be based on nursing science (Alligood, 2010a; and nursing concepts systematically united the nurs-
Fawcett, 1978; Nicoll, 1986). It is as Meleis (2007) ing theoretical works for the discipline. This system
noted, “theory is not a luxury in the discipline of clarified and improved comprehension of knowledge
nursing . . . but an integral part of the nursing lexicon development by positioning the theorists’ works in a

CHAPTER 1  Introduction to Nursing Theory: Its History, Significance, and Analysis 5

larger context, thus facilitating the growth of nursing exciting new era” (p. 2). This awareness ushered in
science (Fawcett, 2005). The body of nursing science the theory utilization era.
and research, education, administration, and prac-
tice continues to expand through nursing scholar- The accomplishments of normal science accompa-
ship. In the last decades of the century, emphasis nied the theory utilization era as emphasis shifted
shifted from learning about the theorists to utiliza- to theory application in nursing practice, education,
tion of the theoretical works to generate research administration, and research (Alligood, 2010c; Wood,
questions, guide practice, and organize curricula. 2010). In this era, middle-range theory and valuing
Evidence of this growth of theoretical works has pro- of a nursing framework for thought and action of
liferated in podium presentations at national and nursing practice was realized. This shift to the appli-
international conferences, newsletters, journals, and cation of nursing theory was extremely important for
books written by nurse scientists who are members theory-based nursing, evidence-based practice, and
of societies as communities of scholars for nursing future theory development (Alligood, 2011a; Alligood,
models and theories. Members contribute to the gen- 2014, in press; Alligood & Tomey, 2010; Alligood &
eral nursing literature and communicate their re- Tomey, 1997, 2002, 2006; Chinn & Kramer, 2011;
search and practice with a certain paradigm model or Fawcett, 2005; Fawcett & Garity, 2009).
framework at conferences of the societies where they
present their scholarship and move the science of the The theory utilization era has restored a balance
selected paradigm forward (Alligood, 2004; Alligood between research and practice for knowledge devel-
2014, in press; Fawcett & Garity, 2009; Im & Chang, opment in the discipline of nursing. The reader is
2012; Parker, 2006). referred to the fifth edition of Nursing Theory: Utili-
zation & Application (Alligood, 2014, in press) for
These observations of nursing theory develop- case applications and evidence of outcomes from
ment bring Kuhn’s (1970) description of normal utilization of nursing theoretical works in practice.
science to life. His philosophy of science clarifies our Table 1-1 presents a summary of the eras of nursing’s
understanding of the evolution of nursing theory search for specialized nursing knowledge. Each era
through paradigm science. It is important histori- addressed nursing knowledge in a unique way that
cally to understand that what we view collectively contributed to the history. Within each era, the per-
today as nursing models and theories is the work of vading question “What is the nature of the knowl-
individuals in various areas of the country who pub- edge that is needed for the practice of nursing?” was
lished their ideas and conceptualizations of nursing. addressed at a level of understanding that prevailed
These works later were viewed collectively within at the time (Alligood, 2010a).
a systematic structure of knowledge according to
analysis and evaluation (Fawcett, 1984, 1993, 2005). This brief history provides some background and
Theory development emerged as a process and prod- context for your study of nursing theorists and their
uct of professional scholarship and growth among work. The theory utilization era continues today,
nurse leaders, administrators, educators, and practi- emphasizing the development and use of nursing
tioners who sought higher education. These leaders theory and producing evidence for professional
recognized limitations of theory from other disci- practice. New theory and new methodologies from
plines to describe, explain, or predict nursing out- qualitative research approaches continue to expand
comes, and they labored to establish a scientific basis ways of knowing among nurse scientists. The utili-
for nursing management, curricula, practice, and zation of nursing models, theories, and middle-
research. The development and use of theory con- range theories for the thought and action of nursing
veyed meaning for nursing processes, resulting in practice contributes important evidence for quality
what is recognized today as the nursing theory era care in all areas of practice in the twenty-first
(Alligood, 2010a; Alligood 2010b; Nicoll, 1986, 1992, century (Alligood, 2010b; Fawcett, 2005; Fawcett &
1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, Garity, 2009; Peterson, 2008; Smith & Leihr, 2008;
2012; Wood, 2010). It was as Fitzpatrick and Whall Wood, 2010). Preparation for practice in the pro-
(1983) had said, “. . . nursing is on the brink of an fession of nursing today requires knowledge of
and use of the theoretical works of the discipline
(Alligood, 2010c).

6 UNIT I  Evolution of Nursing Theories

TABLE 1-1  Historical Eras of Nursing’s Search for Specialized Knowledge

Historical Eras Major Question Emphasis Outcomes Emerging Goal

Curriculum What curriculum content Courses included in Standardized curricula Develop specialized
Era: should student nurses nursing programs for diploma programs knowledge and higher
study to be nurses? education
1900 to 1940s Role of nurses and what Problem studies and
What is the focus for to research studies of nurses Isolated studies do not
Research Era: nursing research? yield unified knowledge
1950 to 1970s Carving out an advanced Nurses have an impor-
What knowledge is role and basis for tant role in health Focus graduate educa-
Graduate Edu- needed for the nursing practice care tion on knowledge
cation Era: practice of nursing? development
There are many ways to Nursing theoretical
1950 to 1970s How do these frame- think about nursing works shift the focus Theories guide nursing
works guide research to the patient research and practice
Theory Era: and practice? Nursing theory guides
1980 to 1990s research, practice, Middle-range theory Nursing frameworks
What new theories education, and may be from quanti- produce knowledge
Theory are needed to produce administration tative or qualitative (evidence) for quality
Utilization Era: evidence of quality approaches care
Twenty-first care?

Century

Alligood, M. R. (2014, in press). Nursing theory: Utilization & application. Maryland Heights, (MO): Mosby-Elsevier.

Significance of Nursing Theory The achievements of the profession over the past
century were highly relevant to nursing science devel-
At the beginning of the twentieth century, nursing opment, but they did not come easily. History shows
was not recognized as an academic discipline or a that many nurses pioneered the various causes and
profession. The accomplishments of the past century challenged the status quo with creative ideas for both
led to the recognition of nursing in both areas. The the health of people and the development of nursing.
terms discipline and profession are interrelated, and Their achievements ushered in this exciting time
some may even use them interchangeably; however when nursing became recognized as both an aca-
they are not the same. It is important to note their demic discipline and a profession (Fitzpatrick, 1983;
differences and specific meaning, as noted in Box 1-1: Kalisch & Kalisch, 2003; Meleis, 2007; Shaw, 1993).
This section addresses the significance of theoretical
BOX 1-1  T he Meaning of a Discipline works for the discipline and the profession of nursing.
and a Profession Nursing theoretical works represent the most com-
prehensive presentation of systematic nursing knowl-
n A discipline is specific to academia and refers edge; therefore, nursing theoretical works are vital to
to a branch of education, a department of the future of both the discipline and the profession
learning, or a domain of knowledge. of nursing.

n A profession refers to a specialized field of prac- Significance for the Discipline
tice, founded upon the theoretical structure of Nurses entered baccalaureate and higher-degree
the science or knowledge of that discipline and programs in universities during the last half of the
accompanying practice abilities. twentieth century, and the goal of developing knowl-
edge as a basis for nursing practice began to be real-
Data from Donaldson, S. K., & Crowley, D. M. (1978). The discipline of ized. University baccalaureate programs proliferated,
nursing. Nursing Outlook, 26(2), 1113–1120.; Orem, D. (2001). Nursing: master’s programs in nursing were developed, and
Concepts of practice (6th ed.). St. Louis: Mosby.; Styles, M. M. (1982).
On nursing: Toward a new endowment. St. Louis: Mosby.

CHAPTER 1  Introduction to Nursing Theory: Its History, Significance, and Analysis 7

a standardized curriculum was realized through theoretical work they had developed for curricula,
accreditation. Nursing had passed through eras of research, or practice.
gradual development, and nursing leaders offered
their perspectives on the development of nursing sci- Also noteworthy, Donaldson and Crowley (1978)
ence. They addressed significant disciplinary ques- presented the keynote address at the Western Com-
tions about whether nursing was an applied science mission of Higher Education in Nursing Conference
or a basic science (Donaldson & Crowley, 1978; in 1977, just as their nursing doctoral program was
Johnson, 1959; Rogers, 1970). History provides about to open. They reopened the discussion of the
evidence of the consensus that was reached, and nature of nursing science and the nature of knowl-
nursing doctoral programs began to open to generate edge needed for the discipline and the profession. The
nursing knowledge. published version of their keynote address has be-
come classic for students to learn about nursing and
The 1970s was a significant period of development. recognize the difference between the discipline and
In 1977, after Nursing Research had been published for the profession. These speakers called for both basic
25 years, studies were reviewed comprehensively, and and applied research, asserting that knowledge was
strengths and weaknesses were reported in the journal vital to nursing as both a discipline and a profession.
that year. Batey (1977) called attention to the impor- They argued that the discipline and the profession are
tance of nursing conceptualization in the research inextricably linked, but failure to separate them from
process and the role of a conceptual framework in the each other anchors nursing in a vocational rather
design of research for the production of science. This than a professional view.
emphasis led the theory development era and moved
nursing forward to new nursing knowledge for nursing Soon nursing conceptual frameworks began to be
practice. Soon the nursing theoretical works began to used to organize curricula in nursing programs and
be recognized to address Batey’s call (Johnson, 1968, were recognized as models that address the values
1974; King, 1971; Levine, 1969; Neuman, 1974; Orem, and concepts of nursing. The creative conceptualiza-
1971; Rogers, 1970; Roy, 1970). tion of a nursing metaparadigm (person, environ-
ment, health, and nursing) and a structure of knowl-
In 1978, Fawcett presented her double helix meta- edge clarified the related nature of the collective
phor, now a classic publication, on the interdependent works of major nursing theorists as conceptual frame-
relationship of theory and research. Also at this time, works and paradigms of nursing (Fawcett, 1984).
nursing scholars such as Henderson, Nightingale, This approach organized nursing works into a system
Orlando, Peplau, and Wiedenbach were recognized of theoretical knowledge, developed by theorists at
for the theoretical nature of their earlier writings. different times and in different parts of the country.
These early works were developed by educators as Each nursing conceptual model was classified on
frameworks to structure curriculum content in nurs- the basis of a set of analysis and evaluation criteria
ing programs. Similarly, Orlando’s (1961, 1972) theory (Fawcett, 1984; 1993). Recognition of the separate
was derived from the report of an early nationally nursing works collectively with a metaparadigm um-
funded research project designed to study nursing brella enhanced the recognition and understanding
practice. of nursing theoretical works as a body of nursing
knowledge. In short, the significance of theory for
I attended the Nurse Educator Nursing Theory the discipline of nursing is that the discipline is
Conference in New York City in 1978, where the ma- dependent upon theory for its continued existence,
jor theorists were brought together on the same stage that is, we can be a vocation, or we can be a discipline
for the first time. Most of them began their presenta- with a professional style of theory-based practice.
tions by stating that they were not theorists. Although The theoretical works have taken nursing to higher
complete understanding of the significance of these levels of education and practice as nurses have moved
works for nursing was limited at the time, many in the from the functional focus, or what nurses do, to a
audience seemed to be aware of the significance of knowledge focus, or what nurses know and how they
the event. After the first few introductions, the audi- use what they know for thinking and decision mak-
ence laughed at the theorists’ denial of being theorists ing while concentrating on the patient.
and listened carefully as each theorist described the

8 UNIT I  Evolution of Nursing Theories BOX 1-2  Criteria for Development of the
Professional Status of Nursing
Frameworks and theories are structures about
human beings and their health; these structures pro- 1. Utilizes in its practice a well-defined and well-
vide nurses with a perspective of the patient for profes- organized body of specialized knowledge
sional practice. Professionals provide public service [that] is on the intellectual level of the higher
in a practice focused on those whom they serve. The learning
nursing process is useful in practice, but the primary
focus is the patient, or human being. Knowledge of 2. Constantly enlarges the body of knowledge it
persons, health, and environment forms the basis for uses and improves its techniques of education
recognition of nursing as a discipline, and this knowl- and service through use of the scientific
edge is taught to those who enter the profession. Every method
discipline or field of knowledge includes theoretical
knowledge. Therefore, nursing as an academic disci- 3. Entrusts the education of its practitioners to
pline depends on the existence of nursing knowledge institutions of higher education
(Butts & Rich, 2011). For those entering the profes-
sion, this knowledge is basic for their practice in the 4. Applies its body of knowledge in practical
profession. Kuhn (1970), noted philosopher of science, services vital to human and social welfare
stated, “The study of paradigms . . . is what mainly
prepares the student for membership in the particular 5. Functions autonomously in the formulation of
scientific community with which he [or she] will later professional policy and thereby in the control
practice” (p. 11). This is significant for all nurses, but it of professional activity
is particularly important to those who are entering the
profession because “in the absence of a paradigm . . . 6. Attracts individuals with intellectual and
all of the facts that could possibly pertain to the devel- personal qualities of exalting service above
opment of a given science are likely to seem equally personal gain who recognize their chosen
relevant” (Kuhn, 1970, p. 15). Finally, with regard to the occupation as a life work
priority of paradigms, Kuhn states, “By studying them
and by practicing with them, the members of their cor- 7. Strives to compensate its practitioners by
responding community learn their trade” (Kuhn, providing freedom of action, opportunity for
1970, p. 43). Master’s students apply and test theoreti- continuous professional growth, and economic
cal knowledge in their nursing practice. Doctoral security
students studying to become nurse scientists develop
nursing theory, test theory, and contribute nursing sci- Data from Bixler, G. K., & Bixler, R. W. (1959). The professional status of
ence in theory-based and theory-generating research nursing. American Journal of Nursing, 59(8), 1142–1146.
studies.
Significance for the Profession These criteria have historical value for enhancing
Not only is theory essential for the existence of nursing our understanding of the developmental path that
as an academic discipline, it is vital to the practice of nurses followed. For example, a knowledge base that is
professional nursing. Recognition as a profession was well defined, organized, and specific to the discipline
a less urgent issue as the twentieth century ended was formalized during the last half of the twentieth
because nurses had made consistent progress toward century, but this knowledge is not static. Rather, it
professional status through the century. Higher-degree continues to grow in relation to the profession’s goals
nursing is recognized as a profession today having used for the human and social welfare of the society that
the criteria for a profession to guide development. nurses serve. So although the body of knowledge is
Nursing development was the subject of numerous important, the theories and research are vital to the
studies by sociologists. Bixler and Bixler (1959) pub- discipline and the profession, so that new knowledge
lished a set of criteria for a profession tailored to nurs- continues to be generated. The application of nursing
ing in the American Journal of Nursing (Box 1-2). knowledge in practice is a criterion that is currently at
the forefront, with emphasis on accountability for
nursing practice, theory-based evidence for nursing
practice, and the growing recognition of middle-range
theory for professional nursing practice (Alligood,
2014, in press).

CHAPTER 1  Introduction to Nursing Theory: Its History, Significance, and Analysis 9

In the last decades of the twentieth century, in enables them to organize and understand what
anticipation of the new millennium, ideas targeted happens in practice, to analyze patient situations
toward moving nursing forward were published. critically for clinical decision making; to plan
Styles (1982) described a distinction between the col- care and propose appropriate nursing interven-
lective nursing profession and the individual profes- tions; and to predict patient outcomes from the
sional nurse and called for internal developments care and evaluate its effectiveness.
based on ideals and beliefs of nursing for continued
professional development. Similarly, Fitzpatrick (1983) (Alligood, 2004, p. 247)
presented a historical chronicle of twentieth century
achievements that led to the professional status of Professional practice requires a systematic approach
nursing. Both Styles (1982) and Fitzpatrick (1983) that is focused on the patient, and the theoretical works
referenced a detailed history specific to the develop- provide just such perspectives of the patient. The theo-
ment of nursing as a profession. Now that nursing is retical works presented in this text illustrate those
recognized as a profession, emphasis in this text is various perspectives. Philosophies of nursing, concep-
placed on the relationship between nursing theoreti- tual models of nursing, nursing theories, and middle-
cal works and the status of nursing as a profession. range theories provide the nurse with a view of the
Similarities and differences have been noted in sets patient and a guide for data processing, evaluation of
of criteria used to evaluate the status of professions; evidence, and decisions regarding action to take in
however, they all call for a body of knowledge that is practice (Alligood 2014, in press; Butts & Rich, 2011;
foundational to the practice of the given profession Chinn & Kramer, 2011; Fawcett & Garity, 2009). With
(Styles, 1982). this background of the history and significance of
nursing theory for the discipline and the profession,
As individual nurses grow in their professional we turn to analysis of theory, a systematic process of
status, the use of substantive knowledge for theory- critical reflection for understanding nursing theoreti-
based evidence for nursing is a quality that is charac- cal works (Chinn & Kramer, 2011).
teristic of their practice (Butts & Rich, 2011). This
commitment to theory-based evidence for practice is Analysis of Theory
beneficial to patients in that it guides systematic,
knowledgeable care. It serves the profession as nurses Analysis, critique, and evaluation are methods used
are recognized for the contributions they make to the to study nursing theoretical works critically. Analysis
health care of society. As noted previously in relation of theory is carried out to acquire knowledge of theo-
to the discipline of nursing, the development of knowl- retical adequacy. It is an important process and the
edge is an important activity for nurse scholars to first step in applying nursing theoretical works to
pursue. It is important that nurses have continued education, research, administration, or practice. The
recognition and respect for their scholarly discipline analysis criteria used for each theoretical work in this
and for their contribution to the health of society. text are included in Box 1-3 with the questions that
Finally and most important, the continued recognition guide the critical reflection of analysis.
of nursing theory as a tool for the reasoning, critical
thinking, and decision making required for quality BOX 1-3  A nalysis Questions to
nursing practice is important because of the following: Determine Theoretical Adequacy

Nursing practice settings are complex, and the n Clarity: How clear is this theory?
amount of data (information) confronting nurses n Simplicity: How simple is this theory?
is virtually endless. Nurses must analyze a vast n Generality: How general is this theory?
amount of information about each patient and n Accessibility: How accessible is this theory?
decide what to do. A theoretical approach helps n Importance: How important is this theory?
practicing nurses not to be overwhelmed by the
mass of information and to progress through the Data from Chinn, P. L., & Kramer, M. K. (2011). Integrated knowledge
nursing process in an orderly manner. Theory development in nursing (8th ed.). St. Louis: Elsevier-Mosby.

10 UNIT I  Evolution of Nursing Theories forms of theory, such as middle range, to guide prac-
tice. A theory should be sufficiently comprehensive,
The analysis process is useful for learning about presented at a level of abstraction to provide guid-
the works and is essential for nurse scientists who ance, and have as few concepts as possible with
intend to test, expand, or extend the works. When simplistic relations to aid clarity. Reynolds (1971)
nurse scientists consider their research interests in contends, “The most useful theory provides the greatest
the context of one of the theoretical works, areas for sense of understanding” (p. 135). Walker and Avant
further development are discovered through the pro- (2011) describe theory parsimony as “brief but com-
cesses of critique, analysis, and critical reflection. plete” (p. 195).
Therefore, analysis is an important process for learn-
ing, for developing research projects, and for expand- Generality
ing the science associated with the theoretical works The generality of a theory speaks to the scope of
of nursing in the future. Understanding a theoretical application and the purpose within the theory (Chinn
framework is vital to applying it in your practice. & Kramer, 2011). Ellis (1968) stated, “The broader
Clarity the scope . . . the greater the significance of the the-
Clarity and structure are reviewed in terms of seman- ory” (p. 219). The generality of a theoretical work
tic clarity and consistency and structural clarity and varies by how abstract or concrete it is (Fawcett,
consistency. Clarity speaks to the meaning of terms 2005). Understanding the levels of abstraction by
used, and definitional consistency and structure speaks doctoral students and nurse scientists facilitated the
to the consistent structural form of terms in the the- use of abstract frameworks for the development
ory. Analysis begins as the major concepts and sub- of middle-range theories. Rogers’ (1986) Theory of
concepts and their definitions are identified. Words Accelerating Change is an example of an abstract
have multiple meanings within and across disciplines; theory from which numerous middle-range theories
therefore, a word should be defined carefully and have been generated.
specifically according to the framework (philosophy,
conceptual model, or theory) within which it is de- Accessibility
veloped. Clarity and consistency are facilitated with Accessibility is linked to the empirical indicators for
diagrams and examples. The logical development and testability and ultimate use of a theory to describe
type of structure used should be clear, and assumptions aspects of practice (Chinn & Kramer, 2011). Acces-
should be stated clearly and be consistent with the goal sible” addresses the extent to which empiric indica-
of the theory (Chinn & Kramer, 2011; Reynolds, tors for the concepts can be identified and to what
1971; Walker & Avant, 2011). Reynolds (1971) speaks extent the purposes of the theory can be attained”
to intersubjectivity and says, “There must be shared (Chinn & Kramer, 2011, p. 203). Reynolds (1971)
agreement of the definitions of concepts and relation- evaluates empirical relevance by examining “the cor-
ships between concepts within a theory” (p. 13). Hardy respondence between a particular theory and the
(1973) refers to meaning and logical adequacy and objective empirical data” (p. 18). He suggests that
says, “Concepts and relationships between concepts scientists should be able to evaluate and verify results
must be clearly identified and valid” (p. 106). Ellis by themselves. Walker and Avant (2011) evaluate
(1968) used “the criterion of terminology” to evaluate testability based on the theory’s capacity to “generate
theory and warns about “the danger of lost meaning hypotheses and be subjected to empirical research”
when terms are borrowed from other disciplines and (p. 195).
used in a different context” (p. 221). Walker and Avant
(2011) assess “logical adequacy” according to “the Importance
logical structure of the concepts and statements” pro- A parallel can be drawn between outcome and impor-
posed in the theory (p. 195). tance. Because research, theory, and practice are
Simplicity closely related, nursing theory lends itself to research
Simplicity is highly valued in nursing theory devel- testing, and research testing leads to knowledge for
opment. Chinn and Kramer (2011) called for simple practice. Nursing theory guides research and practice,

CHAPTER 1  Introduction to Nursing Theory: Its History, Significance, and Analysis 11

generates new ideas, and differentiates the focus Globally, nurses are recognizing the rich heritage
of nursing from that of other professions (Chinn & of the works of nursing theorists, that is, the philoso-
Kramer, 2011). Ellis (1968) indicates that to be con- phies, conceptual models, theories, and middle-
sidered useful, “it is essential for theory to develop range theories of nursing. The publication of this
and guide practice . . . theories should reveal what text in multiple (at least 10) languages reflects the
knowledge nurses must, and should, spend time pur- global use of theory. The contributions of global
suing” (p. 220). theorists present nursing as a discipline and provide
knowledge structure for further development. The
The five criteria for the analysis of theory—clarity, use of theory-based research supports evidence-
simplicity, generality, accessibility, and importance— based practice. There is worldwide recognition of
guide the critical reflection of each theoretical work the rich diversity of nursing values the models rep-
in Chapters 6 to 36. These broad criteria facilitate resent. Today we see added clarification of the theo-
the analysis of theoretical works, whether they are retical works in the nursing literature as more and
applied to works at the level of philosophies, concep- more nurses learn and use theory-based practice.
tual models, theories, or middle-range theories. Most important, the philosophies, models, theories,
and middle-range theories are used broadly in all
Summary areas—nursing education, administration, research,
and practice.
This chapter presents an introduction to nursing
theory with a discussion of its history, significance, There is recognition of normal science in the
and analysis. A nurse increases professional power theoretical works (Wood, 2010). The scholarship
when using theoretical research as systematic evi- of the past 3 decades has expanded the volume
dence for critical thinking and decision making. of nursing literature around the philosophies, mod-
When nurses use theory and theory-based evidence els, theories, and middle-range theories. Similarly,
to structure their practice, it improves the quality of the philosophy of science has expanded and fos-
care. They sort patient data quickly, decide on appro- tered nursing knowledge development with new
priate nursing action, deliver care, and evaluate out- qualitative approaches. As more nurses have ac-
comes. They also are able to discuss the nature of quired higher education, understanding of the im-
their practice with other health professionals. Con- portance of nursing theory has expanded. The use
sidering nursing practice in a theory context helps of theory by nurses has increased knowledge devel-
students to develop analytical skills and critical opment and improved the quality of nursing prac-
thinking ability and to clarify their values and as- tice (Alligood, 2010a; Alligood, 2011b; Chinn &
sumptions. Theory guides practice, education, and Kramer, 2011; Fawcett & Garity, 2009; George,
research (Alligood 2014, in press; Chinn & Kramer, 2011; Im & Chang, 2012; Reed & Shearer, 2012;
2011; Fawcett, 2005; Meleis, 2007). Wood, 2010).

POINTS FOR FURTHER STUDY n Judd, D., Sitzman, K., & Davis, G. M. (2010). A his-
tory of American nursing. Boston: Jones & Bartlett.
n Donaldson, S. K., & Crowley, D. M. (1978). The disci-
pline of nursing. Nursing Outlook, 26(2), 1113–1120. n The Nursing Theory Page at Hahn School of
Nursing, University of San Diego: Retrieved from:
n Fawcett, J. (1984). The metaparadigm of nursing: http://www.sandiego.edu/ACADEMICS/nursing/
current status and future refinements. Image: The theory.
Journal of Nursing Scholarship, 16, 84–87.

n Kalisch, P. A., & Kalisch, B. J. (2003). American
nursing: A history (4th ed.). Philadelphia: Lippincott
Williams & Wilkins.

12 UNIT I  Evolution of Nursing Theories

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Alligood, M. R. (2011a). The power of theoretical knowl-
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Nicoll, L. (1992). Perspectives on nursing theory (2nd ed.). Reed, P., Shearer, N., & Nicoll, L. (2003). Perspectives
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Wilkins.

2CHA P T ER

History and Philosophy of Science

Sonya R. Hardin

“Why should nurses be interested in the history and philosophy of science? The history and philosophy
of science is important as a foundation for exploring whether scientific results are actually

truth. As nurses our practice should be based upon truth and we need the ability to interpret the
results of science. Nursing science provides us with knowledge to describe, explain and predict
outcomes. The legitimacy of any profession is built on its ability to generate and apply theory.”

(McCrae, 2011, p. 222)

Modern science was established over 400 years adults. A recent study tested the theory that a certain
ago as an intellectual activity to formalize given type of question would elicit the most response. The
phenomena of interest in an attempt to describe, theory was confirmed when findings supported that
explain, predict, or control states of affairs in nature. the open-ended questions prompted patients to provide
Scientific activity has persisted because it has improved a larger amount of diagnostically useful pain informa-
quality of life and has satisfied human needs for tion than did the closed-ended questions (McDonald,
creative work, a sense of order, and the desire to under- Shea, Rose, & Fedo, 2009). While this study is one
stand the unknown (Bronowski, 1979; Gale, 1979; example of nursing science, advance practice nurses
Piaget, 1970). The development of nursing science has should be familiar with the long history of the science
evolved since the 1960s as a pursuit to be understood of nursing.
as a scientific discipline. Being a scientific discipline
means identifying nursing’s unique contribution to the Historical Views of the Nature
care of patients, families, and communities. It means of Science
that nurses can conduct clinical and basic nursing
research to establish the scientific base for the care of To formalize the science of nursing, basic questions
individuals across the life span. For example, research must be considered, such as: What is science, knowl-
revealed gaps between the pain management needs edge, and truth? What methods produce scientific
of patients and the information communicated by knowledge? These are philosophical questions. The
patients and clinicians during office visits. Although term epistemology is concerned with the theory of
many older adults have painful but not readily visible knowledge in philosophical inquiry. The particular
conditions (e.g., symptomatic osteoarthritis), little re- philosophical perspective selected to answer these
search has examined how the style or format of a health questions will influence how scientists perform sci-
care practitioner’s questions influence the quality and entific activities, how they interpret outcomes, and
amount of diagnostic information obtained from older even what they regard as science and knowledge

Previous author: Sue Marquis Bishop.
14

CHAPTER 2  History and Philosophy of Science 15

(Brown, 1977). Although philosophy has been docu- additional research is conducted or modifications
mented as an activity for 3000 years, formal science are made in the theory and further tests are devised;
is a relatively new human pursuit (Brown, 1977; otherwise, the theory is discarded in favor of an
Foucault, 1973). Scientific activity has only recently alternative explanation (Gale, 1979; Zetterberg, 1966).
become the object of investigation. Popper (1962) argued that science would evolve more
rapidly through the process of conjectures and refuta-
Two competing philosophical foundations of sci- tions by devising research in an attempt to refute new
ence, rationalism and empiricism, have evolved in ideas. For example, his point is simple; you can never
the era of modern science with several variations. prove that all individuals without social support have
Gale (1979) labeled these alternative epistemologies frequent rehospitalizations since there might be one
as centrally concerned with the power of reason and individual that presents with no rehospitalization. A
the power of sensory experience. Gale noted similarity single person with no social support that does not have
in the divergent views of science in the time of the a readmission disproves the theory that all individuals
classical Greeks. For example, Aristotle believed that with a lack of social support have hospital readmis-
advances in biological science would develop through sions. From Popper’s perspective, “research consists
systematic observation of objects and events in the of generating general hypotheses and then attempting
natural world, whereas Pythagoras believed that knowl- to refute them” (Lipton, 2005, p. 1263). So the hypoth-
edge of the natural world would develop from mathe- esis that a lack of social support results in hospital
matical reasoning (Brown, 1977; Gale, 1979). readmission is the phenomena of interest to be refuted.

Nursing science has been characterized by two The rationalist view is most clearly evident in the
branching philosophies of knowledge as the discipline work of Einstein, the theoretical physicist, who made
developed. Various terms are utilized to describe these extensive use of mathematical equations in developing
two stances: empiricist and interpretive, mechanistic his theories. The theories Einstein constructed offered
and holistic, quantitative and qualitative, and deductive an imaginative framework, which has directed research
and inductive forms of science. Understanding the in numerous areas (Calder, 1979). As Reynolds (1971)
nature of these philosophical stances facilitates appre- noted, if someone believes that science is a process of
ciation for what each form contributes to nursing inventing descriptions of phenomena, the appropriate
knowledge. strategy for theory construction is the theory-then-
research strategy. In Reynolds’ view, “as the continuous
Rationalism interplay between theory construction (invention) and
Rationalist epistemology (scope of knowledge) empha- testing with empirical research progresses, the theory
sizes the importance of a priori reasoning as the becomes more precise and complete as a description
appropriate method for advancing knowledge. A priori of nature and, therefore, more useful for the goals of
reasoning utilizes deductive logic by reasoning from science” (Reynolds, 1971, p. 145).
the cause to an effect or from a generalization to a
particular instance. An example in nursing is to reason Empiricism
that a lack of social support (cause) will result in hos- The empiricist view is based on the central idea that
pital readmission (effect). This causal reasoning is a scientific knowledge can be derived only from sensory
theory until disproven. The traditional approach pro- experience (i.e., seeing, feeling, hearing facts). Francis
ceeds by explaining hospitalization with a systematic Bacon (Gale, 1979) received credit for popularizing
explanation (theory) of a given phenomenon (Gale, the basis for the empiricist approach to inquiry. Bacon
1979). This conceptual system is analyzed by address- believed that scientific truth was discovered through
ing the logical structure of the theory and the logical generalizing observed facts in the natural world. This
reasoning involved in its development. Theoretical approach, called the inductive method, is based on the
assertions derived by deductive reasoning are then idea that the collection of facts precedes attempts to
subjected to experimental testing to corroborate the formulate generalizations, or as Reynolds (1971) called
theory. Reynolds (1971) labeled this approach the it, the research-then-theory strategy. One of the best
theory-then-research strategy. If the research findings examples to demonstrate this form of logic in nursing
fail to correspond with the theoretical assertions,

16 UNIT I  Evolution of Nursing Theories that empirical facts exist independently of theories and
offer the only basis for objectivity in science (Brown,
has to do with formulating differential diagnoses. For- 1977). In this view, objective truth exists independently
mulating a differential diagnosis requires collecting of the researcher, and the task of science is to discover
the facts and then devising a list of possible theories to it, which is an inductive method (Gale, 1979). This
explain the facts. view of science is often presented in research method
courses as: “The scientist first sets up an experiment;
The strict empiricist view is reflected in the work observes what occurs . . . reaches a preliminary hy-
of the behaviorist Skinner. In a 1950 paper, Skinner pothesis to describe the occurrence; runs further ex-
asserted that advances in the science of psychology periments to test the hypothesis [and] finally corrects
could be expected if scientists would focus on the or modifies the hypothesis in light of the results” (Gale,
collection of empirical data. He cautioned against 1979, p. 13).
drawing premature inferences and proposed a mora-
torium on theory building until further facts were The increasing use of computers, which permit the
collected. Skinner’s (1950) approach to theory con- analysis of large data sets, may have contributed to the
struction was clearly inductive. His view of science acceptance of the positivist approach to modern sci-
and the popularity of behaviorism have been credited ence (Snelbecker, 1974). However, in the 1950s, the
with influencing psychology’s shift in emphasis from literature began to reflect an increasing challenge to
the building of theories to the gathering of facts the positivist view, thereby ushering in a new view of
between the 1950s and 1970s (Snelbecker, 1974). The science in the late twentieth century (Brown, 1977).
difficulty with the inductive mode of inquiry is that
the world presents an infinite number of possible Emergent Views of Science and Theory
observations, and, therefore, the scientist must bring in the Late Twentieth Century
ideas to his or her experiences to decide what to
observe and what to exclude (Steiner, 1977). In the latter years of the twentieth century, several
authors presented analyses challenging the positivist
In summary, deductive inquiry uses the theory- position, thus offering the basis for a new perspective
then-research approach, and inductive inquiry uses of science (Brown, 1977; Foucault, 1973; Hanson,
the research-then-theory approach. Both approaches 1958; Kuhn, 1962; Toulmin, 1961). Foucault (1973)
are utilized in the field of nursing. published his analysis of the epistemology (knowledge)
of human sciences from the seventeenth to the nine-
Early Twentieth Century Views teenth century. His major thesis stated that empirical
of Science and Theory knowledge was arranged in different patterns at a
given time and in a given culture and that humans
During the first half of this century, philosophers where emerging as objects of study. In The Phenome-
focused on the analysis of theory structure, whereas nology of the Social World, Schutz (1967) argued that
scientists focused on empirical research (Brown, scientists seeking to understand the social world could
1977). There was minimal interest in the history of not cognitively know an external world that is indepen-
science, the nature of scientific discovery, or the simi- dent of their own life experiences. Phenomenology, set
larities between the philosophical view of science and forth by Edmund Husserl (1859 to 1938) proposed that
the scientific methods (Brown, 1977). Positivism, a the objectivism of science could not provide an ade-
term first used by Comte, emerged as the dominant quate apprehension of the world (Husserl 1931, 1970).
view of modern science (Gale, 1979). Modern logical A phenomenological approach reduces observations or
positivists believed that empirical research and logical text to the meanings of phenomena independent of
analysis (deductive and inductive) were two ap- their particular context. This approach focuses on the
proaches that would produce scientific knowledge lived meaning of experiences.
(Brown, 1977).
In 1977, Brown argued an intellectual revolution
The logical empiricists offered a more lenient view in philosophy that emphasized the history of science
of logical positivism and argued that theoretical propo- was replacing formal logic as the major analytical tool
sitions (proposition affirms or denies something) must
be tested through observation and experimentation
(Brown, 1977). This perspective is rooted in the idea

CHAPTER 2  History and Philosophy of Science 17

in the philosophy of science. One of the major per- are not the single determining factor of the scientist’s
spectives in the new philosophy emphasized science perception. He identified the following three differ-
as a process of continuing research rather than a ent views of the relationship between theories and
product focused on findings. In this emergent episte- observation:
mology, emphasis shifted to understanding scientific 1 . Scientists are merely passive observers of occur-
discovery and process as theories change over time.
rences in the empirical world. Observable data are
Empiricists view phenomena objectively, collect objective truth waiting to be discovered.
data, and analyze it to inductively proposed theory 2. Theories structure what the scientist perceives in
(Brown, 1977). This position is based upon objective the empirical world.
truth existing in the world, waiting to be discovered. 3 . Presupposed theories and observable data interact
Brown (1977) set forth a new epistemology challenging in the process of scientific investigation (Brown,
the empiricist view proposing that theories play a 1977, p. 298).
significant role in determining what the scientist Brown’s argument for an interactionist’s perspective
observes and how it is interpreted. The following story coincides with the scientific consensus in the study of
illustrates Brown’s premise that observations are con- pattern recognition in how humans process informa-
cept laden; that is, an observation is influenced by tion. The following distinct mini-theories have directed
values and ideas in the mind of the observer: research efforts in this area: (1) the data-driven, or
bottom-up, theory and (2) the conceptually driven,
“An elderly patient has been in a trauma and or top-down, theory (Norman, 1976). In the former,
appears to be crying. The nurse on admission cognitive expectations (what is known or ways of orga-
observes that the patient has marks on her body nizing meaning) are used to select input and process
and believes that she has been abused; the ortho- incoming information from the environment. The
pedist has viewed an x-ray and believes that the second theory asserts that incoming data are perceived
crying patient is in pain due to a fractured femur as unlabeled input and analyzed as raw data with in-
that will not require surgery only a closed reduc- creasing levels of complexity until all the data are clas-
tion; the chaplain observes the patient crying and sified. Current research evidence suggests that human
believes the patient needs spiritual support. Each pattern recognition progresses through an interaction
observation is concept laden.” of both data-driven and conceptually driven processes,
and it uses sources of information in both currently
Brown (1977) presented the example of a chemist organized, cognitive categories and in stimuli from the
and a child walking together past a steel mill. The sensory environment. The interactionist’s perspective
chemist perceived the odor of sulfur dioxide and the also is clearly reflected in Piaget’s theory of human
child smelled rotten eggs. Both observers in the exam- cognitive functioning:
ples responded to the same observation but with dis-
tinctly different interpretations. Concepts and theories “Piagetian man actively selects and interprets
set up boundaries and specify pertinent phenomena environmental information in the construction of
for reasoning about specific observed patterns. These his own knowledge, rather than passively copying
examples represent different ideas that emerge for the information just as it is presented to his senses.
each person. While paying attention to and taking account of
the structure of the environment during knowledge
If scientists perceive patterns in the empirical seeking, Piagetian man reconstrues and reinter-
world based on their presupposed theories, how can prets that environment [according to] his own
new patterns ever be perceived or new discoveries mental framework . . . The mind neither copies
become formulated? Gale (1979) answered by pro- the world . . . nor does it ignore the world [by]
posing that the scientist is able to perceive forceful creating a private mental conception of it out of
intrusions from the environment that challenge his whole cloth. The mind meets the environment in
or her a priori mental set, thereby raising questions an extremely active, self-directed way.”
regarding the current theoretical perspective. Brown
(1977) maintained that a presupposed theoretical (Flavell, 1977, p. 6)
framework influences perception, however theories

18 UNIT I  Evolution of Nursing Theories to a normal science, then to a crisis, then to a revolu-
tion, and then to a new normal science. Once normal
If the thesis is accepted that objective truth does science develops, the process begins again when a
not exist and science is an interactive process between crisis erupts and leads to revolution, and a new normal
invented theories and empirical observations, how are science emerges once again (Kuhn, 1970; Nyatanga,
scientists to determine truth and scientific knowledge? 2005). This is what Kuhn refers to as paradigm shift in
In the new epistemology, science is viewed as an the scientific development within a discipline. For
ongoing process. Much importance is given to the idea example, recent research supports that early mobiliza-
of consensus among scientists. As Brown (1977) con- tion of critically ill patients shows better patient out-
cluded, it is a myth that science can establish final comes (Schweickert & Kress, 2011). Theory-based
truths. Tentative consensus based on reasoned judg- nursing practice has demonstrated the capacity to
ments about the available evidence is what can be restructure professional care, improving outcomes
expected. In this view, scientific knowledge is what and satisfaction (Alligood, 2011).
the consensus of scientists in any given historical era
regard as scientific knowledge. At any point in time, Interdependence of Theory
the current consensus among scientists determines the and Research
truth of a given theoretical statement by concluding
whether or not it presents a plausible description of Traditionally, theory building and research have been
reality (Brown, 1977). This consensus is possible presented to students in separate courses. Often, this
through the collaboration of many scientists as they separation has caused problems for students in under-
make their work available for public review and debate standing the nature of theories and in comprehending
and as they build upon previous scientific discoveries the relevance of research efforts (Winston, 1974). The
(Randall, 1964). acceptance of the positivist view of science may have
influenced the sharp distinction between theory and
In any given era and in any given discipline, science research methods (Gale, 1979). Although theory and
is structured by an accepted set of presuppositions that research can be viewed as distinct operations, they
define the phenomena for study and define the appro- are regarded more appropriately as interdependent
priate methods for data collection and interpretation components of the scientific process (Dubin, 1978). In
(Brown, 1977; Foucault, 1973; Kuhn, 1962). These pre- constructing a theory, the theorist must be knowledge-
suppositions set the boundaries for the scientific enter- able about available empirical findings and be able
prise in a particular field. In Brown’s view of the trans- to take these into account because theory is, in part,
actions between theory and empirical observation: concerned with organizing and formalizing available
knowledge of a given phenomenon. The theory is sub-
“Theory determines what observations are worth ject to revision if hypotheses fail to correspond with
making and how they are to be understood, empirical findings, or the theory may be abandoned
and observation provides challenges to accepted in favor of an alternative explanation that accounts
theoretical structures. The continuing attempt to for the new information (Brown, 1977; Dubin, 1978;
produce a coherently organized body of theory Kuhn, 1962).
and observation is the driving force of research,
and the prolonged failure of specific research In contemporary theories of science, the scientific
projects leads to scientific revolutions.” enterprise has been described as a series of phases
with an emphasis on the discovery and verification (or
(Brown 1977, p. 167) acceptance) phases (Gale, 1979; Giere, 1979). These
phases are concerned primarily with the presentation
The presentation and acceptance of a revolution- and testing of new ideas. New ways of thinking about
ary theory may alter the existing presuppositions and phenomena or new data are introduced to the scien-
theories, thereby creating a different set of boundaries tific community during the discovery phase. During
and procedures. The result is a new set of problems or this time, the focus is on presenting a persuasive argu-
a new way to interpret observations; that is, a new ment to show that the new conceptions represent an
picture of the world (Kuhn, 1962). In this view of
science, the emphasis must be placed on ongoing
research rather than established findings. According
to Kuhn, science progresses from a pre-science, then

CHAPTER 2  History and Philosophy of Science 19

improvement over previous conceptions (Gale, 1979). research, the scientific community does not necessarily
Verification is characterized by the scientific commu- reject it. Rather than agreeing that a problem exists with
nity’s efforts to critically analyze and test the new the theory itself, the community may make judgments
conceptions in an attempt to refute them. The new about the validity or the reliability of the measures used
views are then subjected to testing and analyses in testing the theory or about the appropriateness of the
(Gale, 1979). However, Brown (1977) argued that research design. These possibilities are considered in
discovery and verification could not be viewed as critically evaluating all attempts to test a given theory.
distinct phases, because the scientific community does
not usually accept a new conception until it has been Scientific consensus is necessary in three key areas
subjected to significant testing. Only then can it be for any given theory as follows: (1) agreement on the
accepted as a new discovery. boundaries of the theory; that is, the phenomenon it
addresses and the phenomena it excludes (criterion of
In any scientific discipline, it is not appropriate to coherence), (2) agreement on the logic used in con-
judge a theory on the basis of authority, faith, or intu- structing the theory to further understanding from
ition; it should be judged on the basis of scientific a similar perspective (criterion of coherence), and
consensus (Randall, 1964). For example, if a specific (3) agreement that the theory fits the data collected
nursing theory is deemed acceptable, this judgment and analyzed through research (criterion of corre-
should not be made because a respected nursing leader spondence) (Brown, 1977; Dubin, 1978; Steiner, 1977,
advocates the theory. Personal feelings, such as “I like 1978). Essentially, consensus in these three areas
this theory” or “I don’t like this theory,” do not provide constitutes an agreement among scientists to “look at
a valid basis for judgment. The theory should be judged the same ‘things,’ to do so in the same way, and to have
acceptable on the basis of logical and conceptual or a level of confidence certified by an empirical test”
empirical grounds. The scientific community makes (Dubin, 1978, p. 13). Therefore, the theory must be
these judgments (Gale, 1979). capable of being operationalized to test it against
reality.
The advancement of science is thus a collaborative
endeavor in which many researchers evaluate and Scientific inquiry in normal science involves test-
build on the work of others. Theories, procedures, ing a given theory, developing new applications of
and findings from empirical studies must be made a theory, or extending a given theory. Occasionally, a
available for critical review by scientists for evidence new theory with different assumptions is developed
to be cumulative. The same procedures can be used to that could replace previous theories. Kuhn (1962)
support or refute a given analysis or finding. A theory described this as revolutionary science and described
is accepted when scientists agree that it provides a the theory with different presuppositions as a revo-
description of reality that captures the phenomenon lutionary theory. A change in the accepted presup-
based on current research findings (Brown, 1977). positions creates a set of boundaries and procedures
The acceptance of a scientific hypothesis depends on that suggest a new set of problems or a new way to
the appraisal of the coherence of theory, which in- interpret observations (Kuhn, 1962). One previously
volves questions of logic, and the correspondence of accepted theory is abandoned for another theory if
the theory, which involves efforts to relate the theory it fails to correspond with empirical findings or if it
to observable phenomena through research (Steiner, does not present clear directions for further research.
1978). Gale (1979) labeled these criteria as epistemo- The scientific community judges the selected alterna-
logical and metaphysical concerns. tive theory to account for available data and to sug-
gest further lines of inquiry (Brown, 1977). Hence, a
The consensus regarding the correspondence of new worldview is formed.
the theory is, therefore, not based on a single study.
Repeated testing is crucial. The study must be repli- In the social and behavioral sciences, there is some
cated under the same conditions, and the theoretical challenge to the assumptions underlying the accepted
assertions must be explored under different condi- methods of experimental design, measurement, and
tions or with different measures. Consensus is, there- statistical analysis that emphasizes the search for uni-
fore, based on accumulated evidence (Giere, 1979). versal laws and the use of procedures for the random
When the theory does not appear to be supported by assignment of subjects across contexts. Mishler (1979)

20 UNIT I  Evolution of Nursing Theories interaction that emphasize situation, context, and
argued that, in studying behavior, scientists should the multiple cognitive constructions individuals cre-
develop methods and procedures that are dependent ate from everyday events (Ford-Gilboe, et al., 1995).
on context for meaning rather than eliminate context A critical paradigm for knowledge development
by searching for laws that hold across contexts. This in nursing also has been described as an emergent,
critique of the methods and assumptions of research is postmodern paradigm that provides the framework
emerging from phenomenological and ethnomethod- for inquiring about the interaction between social,
ological theorists who view the scientific process from political, economic, gender, and cultural factors
a very different paradigm (Bowers, 1992; Hudson, and the experiences of health and illness (Ford-
1972; Mishler, 1979; Pallikkathayil & Morgan, 1991). Gilboe, et al., 1995). A broad conception of post-
Phenomenology is a science that describes how we modernism includes the particular philosophies that
experience the objects of the external world and pro- challenge the “objectification of knowledge,” such
vides an explanation of how we construct objects of as phenomenology, hermeneutics, feminism, critical
experience. In phenomenology, the investigator posits theory, and poststructuralism (Omery, Kasper, &
that all objects exist because people perceive and Page, 1995).
construct them as such. Ethnomethodology focuses
on the world of “social facts” as accomplished or The philosophy of nursing has been developing
co-created through people’s interpretive work. When over a 150-year period. The philosophy of caring,
examining phenomena from this perspective, social naturalism, and holism are themes that can be found
reality and social facts are constructed, produced, and in the literature. Numerous authors have written
organized through the mundane actions and circum- about caring. Caring is the wholeness of the patient’s
stances of everyday life. situation, which implies that nursing care requires
interpretation, understanding, and hermeneutic ex-
There is neither a single science nor a single scien- perience. The philosophy of caring involves knowl-
tific method. There are several sciences, each with edge, skills, patient trust, and the ability to manage
unique phenomena and structure and methods for all elements simultaneously in the context of care
inquiry (Springagesh & Springagesh, 1986). How- (Austgard, 2008).
ever, the commonality among sciences concerns the
scientists’ efforts to separate truth from speculation Wholism is another philosophy in understanding
to advance knowledge (Snelbecker, 1974). In ques- the patient (Hennessey, 2011). Wholistic nursing
tions regarding the structure of knowledge in a given views the biophysical, psychological, and sociological
science, the consensus of scientists in the discipline subsystems as related but separate, thus the whole is
decides what is to be regarded as scientific knowl- equal to the sum of the parts. Holistic nursing recog-
edge and the methods of inquiry (Brown, 1977; nizes that multiple subsystems are in continuous
Gale, 1979). interaction and that mind-body relationships do exist
(Kinney & Erickson, 1990).
Consensus has emerged in the field of nursing
that the knowledge base for nursing practice is in- Naturalism has a metaphysical component that
complete, and the development of a scientific base implicates that the natural world exists; there is no
for nursing practice is a high priority for the disci- non-natural or supranatural realm. The natural world
pline. The postpositivist and interpretive paradigms is open, because it depends upon what method the
have achieved a degree of acceptance in nursing as enquiry requires. Naturalism insists that knowledge
paradigms to guide knowledge development (Ford- and beliefs are gained by one’s senses guided by
Gilboe, Campbell, & Berman, 1995). Postpositivism reason, and by the various methods of science
focuses on discovering patterns that may describe, (Hussey, 2011). While these philosophies are pro-
explain, and predict phenomena. It rejects the older, posed in the literature, nursing science is in the early
traditional positivist views of an ultimate objective stages of scientific development.
knowledge that is observable only through the senses
(Ford-Gilboe, et al., 1995; Weiss, 1995). The interpre- As the discipline of nursing moves forward, there
tive paradigm tends to promote understanding by is abundant evidence that a greater number of nurse
addressing the meanings of the participants’ social scholars are actively engaged in the advancement
of knowledge for the discipline of nursing through

CHAPTER 2  History and Philosophy of Science 21

research and scholarly dialogue. This can be seen with enterprise (Brown, 1977). For example, the popularity
the emergence of middle-range theories that utilize of certain ideologies may influence how phenomena
inductive, deductive, and synthesis theories from are viewed and what problems are selected for
nursing and other disciplines (Peterson & Bredow, study (Hudson, 1972). In addition, the availability
2008; Sieloff & Frey, 2007; Smith & Liehr, 2008). This of funds for research in a specified area may in-
new century of nursing scholarship by nurse scientists crease research activity in that area. However, sci-
and scholars explores nursing phenomena of interest ence does not depend on the personal characteris-
and provides evidence for quality advanced practice. tics or persuasions of any given scientist or group of
scientists, but it is powerfully self-correcting within
Science as a Social Enterprise the community of scientists (Randall, 1964). Science
progresses by the diversity of dialogue within the
The process of scientific inquiry may be viewed as discipline of nursing. The use of a single paradigm,
a social enterprise (Mishler, 1979). In Gale’s words, multiple paradigms, or the creation of a merged
“Human beings do science” (Gale, 1979, p. 290). paradigm from many paradigms is debated in rela-
Therefore, it might be anticipated that social, eco- tionship to the advancement in the epistemology of
nomic, or political factors may influence the scientific nursing.

POINTS FOR FURTHER STUDY n Phenomenology: http://plato.stanford.edu/
entries/phenomenology/
n 100 Basic Philosophical Terms:http://www.str.org/
site/News2?page5NewsArticle&id55493 n Naturalism: http://plato.stanford.edu/entries/
naturalism/
n Edmund Husserl: http://plato.stanford.edu/
entries/husserl/

n Kant’s Philosophy of Science: http://plato.stanford.
edu/entries/kant-science/

REFERENCES Foucault, M. (1973). The order of things: An archaeology
of the human sciences. New York: Vintage Books.
Alligood, M.R. (2011). Theory-based practice in a major
medical center. Journal of Nursing Management, 19, Gale, G. (1979). Theory of science: An introduction to the
981–988. history, logic and philosophy of science. New York:
McGraw-Hill.
Austgard, K. I. (2008). What characterises nursing care?
A hermenutical philosophical inquiry. Scand J Caring, Giere, R. N. (1979). Understanding scientific reasoning.
22, 314–319. New York: Holt, Rhinehart, & Winston.

Bowers, L. (1992). Ethnomethodology I: an approach to Hanson, N. R. (1958). Patterns of discovery. Cambridge,
nursing research. International Journal of Nursing (MA): Cambridge University Press.
Studies, 29(1), 59–67.
Hennessey, S. (2011). Wholism: another perspective.
Bronowski, J. (1979). The visionary eye: Essays in the California Journal of Oriental Medicine, 22(2),
arts, literature and science. Cambridge, (MA): 7–11.
MIT Press.
Hudson, L. (1972). The cult of the fact. New York: Harper
Brown, H. (1977). Perception, theory and commitment: & Row.
The new philosophy of science. Chicago: University of
Chicago Press. Husserl, E. (1931). Ideas: General introduction to pure
phenomenology. (W. R. Boyce Gibson, Trans.).
Calder, N. (1979). Einstein’s universe. New York: Viking. New York: Humanities Press.
Dubin, R. (1978). Theory building. New York: Free Press.
Flavell, J. H. (1977). Cognitive development. Englewood Husserl, E. (1970). The crisis of European sciences and tran-
scendental phenomenology.(D. Carr, Trans.). Evanston,
Cliffs, (NJ): Prentice-Hall. (IL): Northwestern University Press.
Ford-Gilboe, M., Campbell, J., & Berman, H. (1995).
Hussey, T. (2011). Naturalistic nursing. Nursing Philosophy,
Stories and numbers: coexistence without compromise. 12, 45–52.
Advances in Nursing Science, 18(1), 14–26.

22 UNIT I  Evolution of Nursing Theories Randall, J. H. (1964). Philosophy: An introduction.
New York: Barnes & Noble.
Kinney, C. K., & Erickson, H. C. (1990). Modeling the
client’s world: a way to holistic care. Issues in Mental Reynolds, P. (1971). A primer in theory construction.
Health Nursing, 11(2), 93–108. Indianapolis, (IN): Bobbs-Merrill.

Kuhn, T. S. (1962). The structure of scientific revolutions. Schutz A. (1967). The phenomenology of the social world.
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Kuhn, T. S. (1970). The structure of scientific revolutions Schweickert, W. D., & Kress J. P. (2011). Implementing
(2nd ed.). Chicago: University of Chicago Press. early mobilization interventions in mechanically
ventilated patients in the ICU. Chest, 140, 1612–1617.
Lipton, P. (2005). The Medawar lecture 2004: the truth
about science. Philosophical Transactions of The Royal Sieloff, C. L. & Frey, M. A. (Eds.). (2007). Middle range
Society, 360, 1259–1269. theory development using King’s conceptual system.
New York: Springer.
McCrae, N. (2011). Whither nursing models? The value
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practice and multidisciplinary health care. Journal Psychological Review, 57, 193–216.
of Advanced Nursing, 68(1), 222–229.
Smith, M. J., & Liehr, P. R. (2008). Middle range theory
McDonald, D.D., Shea, M., Rose, L., & Fedo, J. (2009). for nursing. (2nd ed.). New York: Springer.
The effect of pain question phrasing on older adult pain
information. J Pain Symptom Manage, 37, 1050–1060. Snelbecker, G. (1974). Learning theory, instructional theory,
and psychoeducational design. New York: McGraw-Hill.
Mishler, E. G. (1979). Meaning in context: is there any
other kind? Harvard Educational Review, 49, 1–19. Springagesh, K., & Springagesh, S. (1986). Philosophy
and scientific approach. Contemporary Philosophy,
Norman, D. A. (1976). Memory and attention: An 11(6), 18–20.
introduction to human information processing.
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Pallikkathayil, L., & Morgan, S. (1991). Phenomenology as Toulmin, S. (1961). Foresight and understanding. New York:
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Weiss, S. J. (1995). Contemporary empiricism. In A. Omery,
Peterson, S. J., & Bredow, T. S. (2008). Middle range theories: C. E. Kasper, & G. G. Page (Eds.), In search of nursing
Application to nursing research (2nd ed.). Philadelphia: science. Thousand Oaks, (CA): Sage.
Lippincott, Williams & Wilkins.
Winston, C. (1974). Theory and measurement in sociology.
Piaget, J. (1970). The place of the sciences of man in the New York: Wiley.
system of sciences. New York: Harper & Row.
Zetterberg, H. L. (1966). On theory and verification in
Popper, K. (1962). Conjectures and refutations. New York: sociology. Totowa, (NJ): Bedminster Press.
Basic Books.

3CHA P T ER

Theory Development Process

Sonya R. Hardin

“Nursing’s potential for meaningful human service rests
on the union of theory and practice for its fulfillment.”
(Rogers, 1970, p. viii)

Theory development in nursing is an essential Deductive reasoning is narrow and goes from general
component in nursing scholarship to advance the to specific. In the clinical area, nurses often have ex-
knowledge of the discipline. The legitimacy of any perience with a general rule and apply it to a patient.
profession is built on its ability to generate and apply Inductive reasoning is much broader and explor-
theory (McCrae, 2011, p. 222). Nursing theories that atory in nature as one goes from specific to general.
clearly set forth understanding of nursing phenomena Abductive reasoning begins with an incomplete set of
(i.e., self care, therapeutic communication, chronic observations and proceeds to the likeliest possible
sorrow) guide scholarly development of the science of explanation for the set. A medical diagnosis is an
nursing through research. Once a nursing theory is application of abductive reasoning: given this set
proposed addressing a phenomenon of interest, sev- of symptoms, what is the diagnosis that would best
eral considerations follow, such as its completeness explain most of them? One aspect they have in com-
and logic, internal consistency, correspondence with mon is to approach theory development in a precise,
empirical findings, and whether it has been operation- systematic manner, making the stages of development
ally defined for testing. Analyses of these lead logically explicit. The nurse who systematically devises a the-
to the further development of the theory. Scientific evi- ory of nursing and publishes it for the nursing com-
dence accumulates through repeated rigorous research munity to review and debate engages in a process
that supports or refutes theoretical assertions and that is essential to advancing theory development. As
guides modifications or extensions of the theory. Nurs- scholarly work is published in the literature, nurse
ing theory development is not a mysterious activity, but theoreticians and researchers review and critique the
a scholarly endeavor pursued systematically. Rigorous adequacy of the logical processes used in the develop-
development of nursing theories, then, is a high priority ment of the theory with fresh eyes in relation to prac-
for the future of the discipline and the practice of the tice and available research findings.
profession of nursing.
Theory Components
It is important to understand the concept of sys-
tematic development since approaches to construction Development of theory requires understanding of
of theory differ. A theory may emerge through deduc- selected scholarly terms, definitions, and assumptions
tive, inductive, or retroductive (abductive) reasoning.
23
Previous author: Sue Marquis Bishop.

24 UNIT I  Evolution of Nursing Theories directly experienced and relate to a particular time or
place (Chinn & Kramer, 2011; Hage, 1972; Reynolds,
so that scholarly review and analysis may occur. At- 1971) (Table 3-2).
tention is given to terms and defined meanings to
understand the theory development process that was The stretcher, stroke, wheelchair, and hospital bed
used. Therefore, the clarity of terms, their scientific are examples of concrete concepts of the abstract
utility, and their value to the discipline are important concept, transport and the other examples illustrate
considerations in the process. the concrete to abstract difference. In a given theo-
retical system, the definition, characteristics, and
Hage (1972) identified six theory components functioning of a nurse competency clarify more spe-
and specified the contributions they make to theory cific instances, such as medication administration
(Table 3-1). Three categories of theory components nurse competency.
are presented as a basis for understanding the
function of each element in the theory-building Concepts may be classified as discrete or continu-
process. ous concepts. This system of labels differentiates types
Concepts and Definitions of concept that specify categories of phenomena. A
Concepts, the building blocks of theories, classify the discrete concept identifies categories or classes of
phenomena of interest (Kaplan, 1964). It is crucial that phenomena, such as patient, nurse, health, or envi-
concepts are considered within the theoretical system ronment. A student can become a nurse or choose
in which they are embedded and from which they another profession, but he or she cannot become a
derive their meaning, since concepts may have differ- partial nurse. Phenomena identified as belonging to,
ent meanings in various theoretical systems. Scientific or not belonging to, a given class or category may be
progress is based on critical review and testing of a called nonvariable concepts. Sorting phenomena into
researcher’s work by the scientific community. nonvariable discrete categories carries the assump-
tion that the associated reality is captured by the
Concepts may be abstract or concrete. Abstract classification (Hage, 1972). The amount or degree of
concepts are mentally constructed independent of a the variable is not an issue.
specific time or place, whereas concrete concepts are

TABLE 3-1  T heory Components and Their Contributions to the Theory

Theory Components Contributions to the Theory
Concepts and Definitions
Concepts Describe and classify phenomena
Theoretical definitions of concept Establish meaning
Operational definitions of concept Provide measurement
Relational Statements
Theoretical statements Relate concepts to one another; permit analysis
Operational statements Relate concepts to measurements
Linkages and Ordering
Linkages of theoretical statements Provide rationale of why theoretical statements are linked;
add plausibility
Linkages of operational statements
Provide rationale for how measurement variables are linked;
Organization of concepts and definitions into primitive and permit testability
derived terms
Eliminates overlap (tautology)
Organization of statements and linkages into premises and
derived hypotheses and equations Eliminates inconsistency

Modified from Hage, J. (1972). Techniques and problems of theory construction in sociology. New York: John Wiley & Sons.

CHAPTER 3  Theory Development Process 25

TABLE 3-2  Concepts: Abstract versus degrees of marital conflict in their relationships from
Concrete low to high.

Abstract Concepts Concrete Concepts Degree of Marital Conflict

Transport Stretcher, wheelchair, 0         120
hospital bed
Cardiovascular disease Low             High
Telemetry Stroke, myocardial infarction
Loss of relationship Other continuous concepts that may be used to
Nurse competency Electrocardiogram, Holter monitor classify couples might include amount of communi-
cation, number of shared activities, or number of
Divorce, widowhood children. Examples of continuous concepts used to
classify patients are degree of temperature, level of
Cultural, nasogastric tube anxiety, or age. Another example is how nurses con-
placement, medication ceptualize pain as a continuous concept when they
administration ask patients to rate their pain on a scale from 0 to 10
to better understand their pain threshold or pain
Data from Chinn & Kramer, 2011; Hage, 1972; Reynolds, 1971 experience.

Theories may be used as a series of nonvariable Degree of Pain
discrete concepts (and subconcepts) to build typolo- 0      10
gies. Typologies are systematic arrangements of con- Low                High
cepts within a given category. For example, a typology
on marital status could be partitioned into marital Continuous concepts are not expressed in either/
statuses in which a population is classified as married, or terms but in degrees on a continuum. The use of
divorced, widowed, or single. These discrete catego- variable concepts on a continuum tends to focus on
ries could be partitioned further to permit the classi- one dimension but does so without assuming that a
fication of an additional variable in this typology. A single dimension captures all of the reality of the
typology of marital status and gender is shown in phenomenon. Additional dimensions may be de-
Table 3-3. The participants are either one gender or vised to measure further aspects of the phenome-
the other since there are no degrees of how much they non. Instruments may measure a concept and have
are in this discrete category. Taking the illustration subscales that measure discrete concepts related to
further, the typology could be partitioned adding the the overall concept. Variable concepts such as ratio
discrete concept of children. Participants would be of professional to nonprofessional staff, communica-
classified for gender, marital status, and as having or tion flow, or ratio of registered nurses to patients,
not having children. is used to characterize health care organizations.
Although nonvariable concepts are useful in classi-
A continuous concept, on the other hand, permits fying phenomena in theory development, Hage
classification of dimensions or gradations of a phe- (1972) notes several major breakthroughs in disci-
nomenon, indicating degree of marital conflict. Mari- plines as the focus shifts from nonvariable to vari-
tal couples may be classified with a range representing able concepts, because variable concepts permit the
scoring of the phenomenon’s full range of variation.
TABLE 3-3  T ypology of Marital Status
and Gender The development of concepts, then, permits descrip-
tion and classification of phenomena (Hage, 1972). The
Marital Status labeled concept specifies boundaries for selecting phe-
nomena to observe and for reasoning about the phenom-
Participants Single Married Divorced Widowed ena of interest. New concepts may focus attention on new

Male 15   75 23  6
Female 25   72 41 13
Total 40 147 64 19

26 UNIT I  Evolution of Nursing Theories relate the concepts to observable phenomena specify-
phenomena or facilitate thinking about phenomena in a ing empirical indicators. Table 3-5 provides examples
different way (Hage, 1972). Scholarly analysis of the con- of concepts with their theoretical and operational
cepts in nursing theories is a critical beginning step in the definitions. These linkages are vital to the logic of the
process of theoretical inquiry. The concept process con- theory, its observation, and its measurement.
tinues to flourish with many examples in the nursing lit-
erature. See Table 3-4 for references to analyses carried The concept-building process emerges from prac-
out using different approaches. tice, incorporating the literature and research findings
from multiple disciplines. Concepts are built into a
Concept analysis is an important beginning step in conceptual framework and are further refined. A
the process of theory development to develop a con- 10-phase process for concept building is described in
ceptual definition. It is crucial that concepts are clearly the literature (Smith & Liehr, 2008; Smith & Liehr,
defined to reduce ambiguity in the given concept or 2012). The process of concept building is guided by
set of concepts. To eliminate perceived differences in patient stories. The 10 phases are as follows: (1) write a
meaning, explicit definitions are necessary. As the meaningful practice story; (2) name the central phe-
theory develops, theoretical and operational defini- nomenon in the practice story; (3) identify a theoretical
tions provide the theorist’s meaning of the concept lens for viewing the phenomenon; (4) link the phenom-
and the basis for the empirical indicators. For exam- enon to existing literature; (5) gather a story from some-
ple, McMahon and Fleury (2012) published a concept one who has lived the phenomenon; (6) reconstruct the
analysis on wellness in older adults. Wellness in older shared story (from Phase 5) and create a mini-saga that
adults was theoretically defined as wellness is a pur- captures its message; (7) identify the core qualities of
poseful process of individual growth, integration of the phenomenon; (8) use the core qualities to create a
experience, and meaningful connection with others, definition; (9) create a model of the phenomenon; and
reflecting personally valued goals and strengths, and (10) write a mini-synthesis that integrates the phe-
resulting in being well and living values. The concept nomenon with a population to suggest a research direc-
of wellness in older adults was operationalized as an tion. The process, which provides the scaffolding for
ever changing process of becoming, integrating, and beginning scholars to move from the familiarity of
relating. practice to the unfamiliarity of phenomena for research,
will be shared with brief examples that demonstrate
Theories are tested in reality; therefore, the con-
cepts must be linked to operational definitions that

TABLE 3-4  Examples of Published Concept Analyses with Different Approaches

Concept Approach Author

Spirituality Chinn & Kramer Buck (2006)
Readiness to change Chinn & Kramer Dalton & Gottlieb (2003)
Acculturation Morse Baker (2011)
Ethical sensitivity Morse Weaver, Morse, & Mitcham (2008)
Disability and aging Rodgers Greco & Vincent (2011)
Moral distress in neuroscience nursing Rodgers Russell (2012)
Symptom perception Schwartz-Barcott & Kim Posey (2006)
Being sensitive Schwartz-Barcott & Kim Sayers, K., & de Vries, K. (2008)
Work engagement in nursing Walker & Avant Bargagliotti (2012)
Migration Walker & Avant Freeman, Baumann, Blythe, Fisher, & Akhtar-Danesh (2012)
Infant distress Wilson method Hatfield & Polomano (2012)
Social justice Wilson method Buettner-Schmidt & Lobo (2012)

CHAPTER 3  Theory Development Process 27

TABLE 3-5  Examples of Theoretical and Operational Definitions

Concept Theoretical Definition Operational Definition

Body temperature Homeothermic range of one’s internal environment Degree of temperature measured by oral
Quality of Life maintained by the thermoregulatory system of thermometer taken for 1 minute under the
Spirituality the human body tongue

Perceptions of the effects of heart failure and its The physical, emotional, social, and mental
treatment on daily life* dimensions of daily life when diagnosed with
heart failure as measured with the Minnesota
A pandimensional awareness of the mutual Living with Heart Failure Questionnaire†
human/environmental field process (integrality)
as a manifestation of higher-frequency Score on the Spiritual Inventory Belief Scale
patterning (resonancy) associated with (SIBS), an instrument that measures a person’s
innovative, increasingly creative and diverse spirituality as the search for meaning and
(helicy) experiences‡ purpose§

The SIBS has four subscales:
1 ) Internal/fluid
2 ) Humility/personal application
3) External/meditative
4) External/ritual¶

*Hussey & Hardin, 2003.
†Rector & Cohen, 1992.
‡Malinski, 1994.
§Hatch, Burg, Naberhaus, & Hellmich, 1998.

¶Hardin, Hussey, & Steele, 2003.

potential and lessons learned in nearly a decade of use in the development of a theory. These statements can
(Smith & Liehr, 2012, p. 65). be reformulated later as the theory evolves or as new
information becomes available. An example of an
Relational Statements antecedent and a consequent variable is explained
Statements in a theory may state definitions or rela- looking at the concept of well in older adults, where
tions among concepts. Whereas definitions provide the antecedents were identified as connecting with
descriptions of the concept, relational statements pro- others, imagining opportunities, recognizing strengths,
pose relationships between and among two or more and seeking meaning. The consequences identified
concepts. Concepts are the building blocks of theory, were living values and being well. These antecedents
and theoretical statements are the chains that link the and consequences were developed from the literature
blocks to build theory. Concepts must be connected (McMahon & Fleury, 2012).
with one another in a series of theoretical statements
to devise a nursing theory. Theoretical assertions are either a necessary or suf-
ficient condition, or both. These labels characterize
In the connections between variables, one vari- conditions that help explain the nature of the relation-
able may be proposed to influence a second. In this ship between two variables in theoretical statements.
case, the first variable may be viewed as the anteced- For example, a relational statement expressed as a
ent or determinate (independent) variable and the sufficient condition could be: If nurses react with
second as the consequent or resultant (dependent) approval of patients’ self-care behaviors (NA), patients
variable (Giere, 1997). Zetterberg (1966) concluded increase their efforts in self-care activities (PSC). This
that the development of two-variate theoretical is a type of compound statement linking antecedent and
statements could be an important intermediate step consequent variables. The statement does not assert

28 UNIT I  Evolution of Nursing Theories

the truth of the antecedent. Rather, the assertion is case, (1) the consequent never occurs in the absence
made that if the antecedent is true, then the conse- of the antecedent and (2) the consequent always
quent is true (Giere, 1979). In addition, no assertion occurs when the antecedent occurs (Giere, 1979). It
appears in the statement explaining why the anteced- should be noted that not all conditional statements
ent is related to the consequent. In symbolic notation are causal. For example, “If this month is November,
form, the statements may be expressed as: then the next month is December,” does not assert
that November causes December to occur; rather, the
NA PSC sequence of months suggests that December follows
Consequent/ November (Dubin, 1978; Giere, 1979).
(Antecedent/determinant
resultant) Giere (1997) further differentiates deterministic
models from probabilistic models in his discussion of
A sufficient condition asserts that one variable causal statements. Theoretical statements from a de-
results in the occurrence of another variable. It does terministic model assert that the presence or absence
not claim it is the only variable that can result in of one variable determines the presence or absence of
the occurrence of the other variable. This statement a second variable. The probabilistic model is another
asserts that nurse approval of a patient’s self-care approach that views humans as complex social and
behaviors is sufficient for the occurrence of the patient’s environmental phenomena best conceptualized from
self-care activities. However, patient assumption of a probability framework. Probabilistic statements
self-care activities resulting from other factors, such generally are based on statistical data and assert
as the patient’s health status and personality variables, relationships between variables that do not occur in
is not ruled out. There may be other antecedent con- every instance, but are likely to occur based on some
ditions sufficient for the patient’s assumption of self- estimate of probability. As an example, it has been
care activities. asserted that a lack of exercise may lead to obesity, a
growing national health problem. It is clear that a lack
A statement in the form of a necessary condition of exercise (LE) does not always lead to obesity, be-
asserts that one variable is required for the occur- cause not all couch potatoes become medically obese
rence of another variable. For example: If patients are (MO). However, the probability of developing medi-
motivated to get well (WM 5 wellness motivation) cal obesity (P MO) may be increased for persons who
then they adhere to their prescribed treatment regi- routinely avoid exercise at least to some degree of
men (AR). probability. In symbolic notation:

WM AR IF LE P MO
This means that adherence to a treatment regimen Relational statements that assert connections
(AR) never occurs unless wellness motivation (WM) between variables provide for analysis and establish
occurs. It is not asserted that the patients’ adherence a basis for explanation and prediction (Hage, 1972).
to the treatment regimen stems from their wellness
motivation. However, it is asserted that if the wellness Linkages and Ordering
motivation is absent, patients will not assume strict Specification of linkages is a vital part of the develop-
adherence to their treatment regimens. The wellness ment of theory (Hage, 1972). Although the theoretical
motivation is a necessary, but not a sufficient, condi- statements assert connections between concepts, the
tion for the occurrence of this consequent. rationale for the stated connections must be developed
The term if is generally used to introduce a suffi- and clearly presented. Development of theoretical link-
cient condition, whereas only if and if . . . then are ages provides an explanation of why the variables
used to introduce necessary conditions (Giere, 1979). are connected in a certain manner; that is, the theo-
Usually conditional statements are not both necessary retical reason for particular relationships (Hage,
and sufficient. However, it is possible for a statement 1972). Operational linkages contribute testability to
to express both conditions. In such instances, the the theory by specifying how measurement variables
term if and only if is used to imply that conditions are are connected (Hage, 1972). Operational definitions
both necessary and sufficient for one another. In this

CHAPTER 3  Theory Development Process 29

specify the measurability of the concepts, and opera- concepts that are necessary to understand the phe-
tional linkages provide the testability of the assertions. nomenon of interest (Foster, 1997).
It is the operational linkages that contribute a perspec-
tive for understanding the nature of the relationship Reynolds (1971) concluded that the set-of-laws
between concepts, to know whether the relationship approach provides for classification of phenomena or
between the concepts is negative or positive, linear, or prediction of relationships between selected variables,
curvilinear (Hage, 1972). A theory may be considered however it does not further understanding or advance
fairly complete if it presents the concepts, definitions, science since it is based on what is already known.
relational statements, and linkages. Complete develop- Finally, Reynolds (1971) notes that each statement
ment of a theory, however, requires organizing the or law is considered to be independent, since the
concepts, definitions, relational statements, and link- various statements have not been interrelated into a
ages into premises and hypotheses (Hage, 1972). A system of description and explanation or evolved
premise is a proposition upon which an argument is from an organized conceptual model or framework.
based or from which a conclusion is drawn. A hypoth- Table 3-6 describes the principles of theory develop-
esis is a proposed explanation made on the basis of ment: laws, hypotheses, and theory. Therefore, each
limited evidence as a starting point for further investi- statement must be tested since the statements are not
gation. As the theory evolves, concepts and theoretical interrelated, and one statement does not provide
statements are developed establishing a logical organi- support for another statement. This set of laws may
zation of the theory components. The conceptual ar- be useful to begin theory development; however,
rangement of statements and linkages into premises research efforts must be more extensive.
reveals any areas of inconsistency (Hage, 1972). Prem-
ises (or axioms) are the more general assertions from The organizationof a theory is an interrelated, logi-
which the hypotheses are derived. It is generally agreed cal system. Specifically, a theory consists of explicit
that conceptual ordering of theoretical statements and definitions, a set of concepts, a set of existence state-
their linkages is indicated when the theory contains a ments, and a set of relationship statements arranged
logical list of theoretical statements. in hierarchical order (Reynolds, 1971). The concepts
may include abstract, intermediate concepts, and
Reynolds (1971) describes three forms for organiz- concrete concepts. The set-of-existence statements
ing theory: laws, theory, and causal process (prediction). describe situations in which the theory is applicable.
Each is a different conceptual approach to organization Statements that delineate the boundaries describe
with different limitations. Establishing a set of laws or- the scope of the theory (Dubin, 1978; Hage, 1972;
ganizes findings from available research in an area of
particular interest from the literature for evaluation. TABLE 3-6  Theory Development
Findings are evaluated and sorted into the categories of Principles
laws and hypotheses based on the degree of research
evidence supporting each assertion (Reynolds, 1971). Principle Definition Proof
Limitations to the set-of-laws approach to theory
building have been noted. Scientific A statement of fact Simple, true,
laws meant to describe universal, and
First, the nature of research requires focusing on an action or a set of absolute
the relationships between a limited set of variables, Hypothesis actions.
therefore attempts to develop a set-of-laws theory Theory Has not been
from statements of findings may result in a lengthy An educated guess based proved
number of statements asserting relationships between upon observation
but limited to two or more variables. The lengthy set Accepted at true
of generalizations may be difficult to organize and One or more hypotheses and proved
interrelate. Second, for research to be conducted, con- that explains a set of
cepts must be operationally defined so they can related observations
be measurable. Therefore, the reported empirical or events and has
findings may eliminate the abstract or theoretical been verified multiple
times

30 UNIT I  Evolution of Nursing Theories incorporating Newton’s law of gravitation is a classic
Reynolds, 1971). Relational statements consist of example. Axiomatic theories (theories with equations)
axioms and propositions. Abstract, theoretical state- are less common in the social and behavioral sci-
ments, or axioms, are at the top of the hierarchy ences, but they are quite evident in the fields of phys-
of relational statements. The other propositions are ics and mathematics.
developed through logical deduction from the axioms
or from research findings in the literature (Table 3-7). Developing theories in axiomatic form has several
This results in a highly interrelated, explanatory advantages (Reynolds, 1971; Salmon, 1973). First,
system. because theory is a set of interrelated statements in
which some statements derive from others, only con-
Theorists avoid the problem of contradictory axi- cepts to be measured need to be operationally de-
oms by using a conceptual system with a few broad fined (Reynolds, 1971). This allows the theorist to
axioms from which a set of propositions are derived. incorporate highly abstract less measurable concepts
The seven nursing conceptual models (Unit III, to provide explanation. The theoretical system also
Chapters 12 to 18) in this text are examples of may be more efficient for explanation than a lengthy
frameworks with broad axioms from which theory number of theoretical statements in the form of laws.
may be developed. As science progresses and new In addition, empirical support for one theoretical
empirical data are known, the general axioms may statement may be based on findings of support from
be modified or extended. Examples of this type of earlier research, thereby permitting less extensive
extension are some of the nursing theories and research than the requirement to test each statement
middle-range theories that were developed using a in the laws form. In certain instances, the theory may
nursing conceptual model as their broad axioms. be organized in a causal process form to increase
However, these additions must be consistent with understanding and substantiate findings.
the logical system of the model and not include con-
tradictions in the theory, or the theory will be re- The distinguishing feature of the causal process
jected (Schlotfeldt, 1992). New theories may also form of theory development is the theoretical state-
subsume portions of previous theories as special ments that specify causal mechanisms between inde-
cases (Brown, 1977). Einstein’s theory of relativity pendent and dependent variables. Hence, the states

TABLE 3-7  Theory Development in the Scientific Method

Steps Example

Observation: Start with an observation that evokes a Autotransfusion is time-consuming for nurses caring for total knee
question. replacement patients.

Logical hypothesis: Using abductive, inductive, or deductive Autotransfusion patients have a higher hemoglobin level at discharge
logic, state a possible answer (hypothesis). than allogenic blood recipients.

Testing: Perform an experiment or test. Autotransfusion use results in an increased hemoglobin level at
discharge.
Dissemination: Publish your findings for the discipline.
Poulin-Tabor, D., & Hyrkas, K. (2008). Evaluation of postoperative
Replication: Other scientists will read your published blood salvage and re-transfusion in a total knee arthoplasty
work and try to duplicate it (verification). patient population: A retrospective study. MEDSURG Nursing,
17(5), 317-321.
Theory: If experiments from other researchers support
your hypothesis, it will become a theory. Faber, F. C., & Hardin, S. R. (2010). Outcomes of knee replacement
patients using autotransfusion. Orthopedic Nursing, 29(5), 333-337.

Findings: No significant difference in hemoglobin

No theory

CHAPTER 3  Theory Development Process 31

are to some degree attempting to predict. This form highly developed form of theory development that
of theory organization consists of a set of concepts, a builds successively on previous research findings in
set of definitions, a set of existence statements, and a the researchers’ area of research with extensive theory
set of theoretical statements specifying a causal pro- building and testing over time. Figure 3-1 displays a
cess (Reynolds, 1971). Concepts include abstract and causal model for testing a theory of active coping. The
concrete ideas. Existence statements function as they broken lines show direction of expected linkage. The
do in axiomatic theories to describe the scope condi- dotted lines indicate potential new relationships.
tions of the theory; that is, the assumed situations The arrows indicate the direction of cause that is pre-
where the theory applies (Dubin, 1978; Hage, 1972; dicted in the hypotheses of the study. The numbers
Reynolds, 1971). Causal statements specify the hy- along the lines identify previous studies that lend sup-
pothesized effects of one variable upon one or more port for the relationships being proposed.
other variables for testing. In complex causal pro-
cesses, feedback loops and paths of influence through Contemporary Issues in Nursing
several variables are hypothesized in a set of interre- Theory Development
lated causal statements (Mullins, 1971; Nowak, 1975).
Reynolds (1971) concludes that the causal process Theoretical Boundaries and Levels
form of theory provides for testing an explanation to Advance Nursing Science
of the process of how events happen. He identified
several advantages of the causal process form of orga- Since Fawcett’s (1984) seminal proposal of the four
nization. First, like axiomatic theory, it provides for metaparadigm concepts: person, environment, health,
highly abstract, theoretical concepts. Second, like and nursing, general agreement has emerged among
axiomatic theory, this form permits more efficient nursing scholars such that the proposed framework
research testing with its interrelated theoretical state- is now used without reference to the author for the
ments. Finally, the causal process statements provide development of nursing science. In general, a metapar-
a sense of understanding in the phenomenon of inter- adigm should specify the broad boundaries of the
est that is not possible with other forms. This is a phenomenon of concern in a discipline, for example,
to set nursing apart from other disciplines, such as

1,2,3,4 (+) Passive/ 1,3 (+)
1,2,3 (+) avoidance Psychological

1,2,3,4 (+) Perceived coping distress
stress
1,2,3 (+)
1,2,3 (+)

Conflicts

1,2,3 (+)

Available/ 1,2,4 (+) Active
enacted coping
social support

FIGURE 3-1  C​ ausal model of active coping. (From Ducharme, F., Ricard, N., Duquette, A., & Lachance, I.
(1998). Empirical testing of a longitudinal model derived from the Roy Adaptation Model. Nursing Science

Quarterly, 11(4), 149–159.)